Healthcare Provider Details

I. General information

NPI: 1629398433
Provider Name (Legal Business Name): CLEANSLATE CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 MAIN ST
WEST SPRINGFIELD MA
01089-3942
US

IV. Provider business mailing address

PO BOX 32
NORTHAMPTON MA
01061
US

V. Phone/Fax

Practice location:
  • Phone: 413-788-0100
  • Fax: 413-736-1813
Mailing address:
  • Phone: 413-788-0100
  • Fax: 413-736-1813

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 Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. AMANDA L WILSON
Title or Position: OWNER
Credential: MD
Phone: 413-788-0100