Healthcare Provider Details

I. General information

NPI: 1104755339
Provider Name (Legal Business Name): MAHALIA MINTON LADC I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 PLANTATION ST APT 319
WORCESTER MA
01605-2371
US

IV. Provider business mailing address

501 PLANTATION ST APT 319
WORCESTER MA
01605-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-921-5743
  • Fax: 617-921-5743
Mailing address:
  • Phone: 617-921-5743
  • Fax: 617-921-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25250
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: