Healthcare Provider Details

I. General information

NPI: 1396848404
Provider Name (Legal Business Name): GWEN E. CARELLI LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 RUSSELL ST
WORCESTER MA
01609-2265
US

IV. Provider business mailing address

122 NEW ESTATE RD
LITTLETON MA
01460-1100
US

V. Phone/Fax

Practice location:
  • Phone: 508-753-5554
  • Fax: 508-752-7245
Mailing address:
  • Phone: 978-501-6450
  • Fax: 508-752-7245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4731
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: