1750648689 NPI number — ADVANCED PSYCH SERVICES, LLC

Table of content: (NPI 1750648689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750648689 NPI number — ADVANCED PSYCH SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED PSYCH SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ISLAND COUNSELING CENTER, LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750648689
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 LAKE AVE N STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WORCESTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01605-2047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-753-3220
Provider Business Mailing Address Fax Number:
508-753-3224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 LAKE AVE N STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-753-3220
Provider Business Practice Location Address Fax Number:
508-753-3224
Provider Enumeration Date:
04/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
OCH
Authorized Official First Name:
MOHAMAD
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
508-753-3220

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110094330B , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110094330A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com