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General NPI Number Information
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NPI Number | 1477921781
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Entity Type | Organization
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Legal Business Name | COUNSELING AND NUTRITION CENTER 360, LLC
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Dates
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Enumeration Date | 09/03/2015
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Last Update Date | 09/03/2015
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Provider Practice Location Address
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Address Line | 33 BEDFORD ST SUITE 20
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City | LEXINGTON
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State | MA
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Zip | 02420-4319
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Country | US
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Telephone | 781-674-1189
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Fax | 781-863-2646
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Provider Business Mailing Address
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Address Line | 33 BEDFORD ST SUITE 20
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City | LEXINGTON
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State | MA
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Zip | 02420-4319
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Country | US
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Telephone | 781-674-1189
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Fax | 781-863-2646
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Authorized Official
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Title or Position | OWNER
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Name | MS. ELIZABETH MARIE PEARL
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Credential | MS, RD, LDN, CEDS
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Telephone | 781-674-1189
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 118496
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6779
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License Number State | MA
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