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General NPI Number Information
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NPI Number | 1457894628
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Entity Type | Organization
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Legal Business Name | PSYCHE1001 LEARN GROW CHANGE LLC
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Dates
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Enumeration Date | 11/21/2016
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Last Update Date | 11/21/2016
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Provider Practice Location Address
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Address Line | 638 ADAMSVILLE RD SUITE 1001
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City | WESTPORT
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State | MA
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Zip | 02790-5031
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Country | US
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Telephone | 508-636-4769
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Fax | 508-636-6463
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Provider Business Mailing Address
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Address Line | 638 ADAMSVILLE RD
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City | WESTPORT
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State | MA
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Zip | 02790-5031
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Country | US
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Telephone | 508-636-4769
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Fax | 508-636-6463
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Authorized Official
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Title or Position | OWNER
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Name | MS. MARCI A MCNICOL
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Credential | APRNCNS BC
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Telephone | 508-636-4769
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 364SP0809X
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Taxonomy Name | Adult Psychiatric/Mental Health Clinical Nurse Specialist
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License Number | APRN00561
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License Number State | RI
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