Healthcare Provider Details

I. General information

NPI: 1427453000
Provider Name (Legal Business Name): WALTHAM BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2014
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BEAR HILL RD SUITE 202
WALTHAM MA
02451-1025
US

IV. Provider business mailing address

210 BEAR HILL ROAD SUITE 202
WALTHAM MA
02451-1025
US

V. Phone/Fax

Practice location:
  • Phone: 781-966-0070
  • Fax: 781-915-0755
Mailing address:
  • Phone: 781-966-0070
  • Fax: 781-915-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7194
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113314
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number205807
License Number StateMA
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number280722
License Number StateMA
# 7
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number175264
License Number StateMA
# 8
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MS. ELEFTHERIA TSAVOUSSIS
Title or Position: OWNER
Credential: PMSCNSBC
Phone: 781-966-0070