1063062107 NPI number — SKILLS FOR CHANGE THERAPY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063062107 NPI number — SKILLS FOR CHANGE THERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKILLS FOR CHANGE THERAPY PLLC
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:
Provider Other Organization Name Type Code:
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:
1063062107
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 BUTTERNUT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02726-1511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-493-8494
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
331 PAGE ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOUGHTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02072-1172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-493-8494
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PELLETIER
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/SOCIAL WORKER
Authorized Official Telephone Number:
508-493-8494

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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