Healthcare Provider Details

I. General information

NPI: 1861897951
Provider Name (Legal Business Name): COLLEEN R MCINNIS MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN R MCINNIS ROEF MED

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PROSPECT ST
NASHUA NH
03060-3923
US

IV. Provider business mailing address

7 PROSPECT ST
NASHUA NH
03060-3921
US

V. Phone/Fax

Practice location:
  • Phone: 603-889-6147
  • Fax: 603-594-9649
Mailing address:
  • Phone: 603-889-6147
  • Fax: 603-594-9649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: