=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134984669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OFLONG MENTAL HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2024
-----------------------------------------------------
Last Update Date | 02/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 365 MAIN ST
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01608-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-963-6934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 FOSTER ST STE 301
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01608-1760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-963-6934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BENEDICTA GOMASHIE
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 508-963-6934
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------