Healthcare Provider Details

I. General information

NPI: 1457894628
Provider Name (Legal Business Name): PSYCHE1001 LEARN GROW CHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 ADAMSVILLE RD SUITE 1001
WESTPORT MA
02790-5031
US

IV. Provider business mailing address

638 ADAMSVILLE RD
WESTPORT MA
02790-5031
US

V. Phone/Fax

Practice location:
  • Phone: 508-636-4769
  • Fax: 508-636-6463
Mailing address:
  • Phone: 508-636-4769
  • Fax: 508-636-6463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberAPRN00561
License Number StateRI

VIII. Authorized Official

Name: MS. MARCI A MCNICOL
Title or Position: OWNER
Credential: APRNCNS BC
Phone: 508-636-4769