MEDICARE: MR. DANIEL MENDES DEPINA M.ED. LADC I, MA PG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1073817573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANIEL MENDES DEPINA M.ED. LADC I, MA PG

Provider Business Mailing Address
First Line	:	682 NORTH MAIN STREET
Second Line	:	APT. 308
City	:	BROCKTON
State	:	MA
Zip	:	02301-3626
Country	:	US
Telephone Number	:	508-857-9058
Fax Number	:

Provider Business Practice Location Address
First Line	:	682 NORTH MAIN STREET
Second Line	:	APT. 308
City	:	BROCKTON
State	:	MA
Zip	:	02301-3626
Country	:	US
Telephone Number	:	508-857-9058
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2010
Last Update Date	:	08/07/2020

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