Healthcare Provider Details

I. General information

NPI: 1700122645
Provider Name (Legal Business Name): CENTER FOR INTEGRATIVE PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PLEASANT ST SUITES 1-4
CONCORD NH
03301-4026
US

IV. Provider business mailing address

15 PLEASANT ST SUITE 3
CONCORD NH
03301-4026
US

V. Phone/Fax

Practice location:
  • Phone: 603-223-0908
  • Fax: 603-223-0908
Mailing address:
  • Phone: 603-223-0908
  • Fax: 603-223-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number834
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number1198
License Number StateNH

VIII. Authorized Official

Name: LAURIE L GUIDRY
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 603-223-0908