=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235913468
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE HARRY SUCH JR. LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2023
-----------------------------------------------------
Last Update Date | 08/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 COLONY RD
-----------------------------------------------------
City | GARDNER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01440-4239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-638-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 BROOK DR
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03451-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-336-6168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------