=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306599493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIBE INSTITUTE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2022
-----------------------------------------------------
Last Update Date | 02/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 N MAIN ST STE 2
-----------------------------------------------------
City | EAST LONGMEADOW
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01028-1814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-224-2008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 280 N MAIN ST STE 2
-----------------------------------------------------
City | EAST LONGMEADOW
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01028-1814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-224-2008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | DR. WINIFRED MARTIN
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 413-657-6190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------