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General NPI Number Information
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NPI Number | 1093011413
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Entity Type | Organization
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Legal Business Name | NATIONAL STRESS CLINIC, LLC
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Dates
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Enumeration Date | 02/02/2011
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Last Update Date | 02/02/2011
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Provider Practice Location Address
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Address Line | 1201 N ORANGE ST SUITE 600
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City | WILMINGTON
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State | DE
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Zip | 19801-1155
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Country | US
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Telephone | 646-571-8627
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Fax |
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Provider Business Mailing Address
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Address Line | 150 PLEASANT ST
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City | NEWTON
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State | MA
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Zip | 02459-1828
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. TIM JACKSON
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Credential |
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Telephone | 646-571-8627
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 03127
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2592-057
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1214
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License Number State | HI
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | MFT (MFC) 37695
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 071-005431
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License Number State | IL
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