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General NPI Number Information
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NPI Number | 1265971626
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Entity Type | Organization
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Legal Business Name | FORTITUDE COUNSELING & RECOVERY CENTER, LLC
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Dates
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Enumeration Date | 02/17/2017
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Last Update Date | 01/09/2018
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Provider Practice Location Address
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Address Line | 69 HOLMES ST
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City | QUINCY
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State | MA
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Zip | 02171-2419
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Country | US
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Telephone | 617-481-8991
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Fax | 617-481-6581
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Provider Business Mailing Address
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Address Line | PO BOX 690602
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City | QUINCY
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State | MA
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Zip | 02269
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Country | US
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Telephone | 617-481-8991
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Fax | 617-481-6581
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Authorized Official
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Title or Position | CEO/DIRECTOR OF OUTPATIENT SERVICES
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Name | NICOLE H KASIMATIS
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Credential |
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Telephone | 617-481-8991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 114423
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License Number State | MA
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