1487010799 NPI number — MENTAL FITNESS AND PSYCHOTHERAPY

Table of content: (NPI 1487010799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487010799 NPI number — MENTAL FITNESS AND PSYCHOTHERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENTAL FITNESS AND PSYCHOTHERAPY
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:
1487010799
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 FULTON ST
Provider Second Line Business Mailing Address:
UNIT 1
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02109-1422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-241-2878
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1318 BEACON ST
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
BROOKLINE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02446-3704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-419-0643
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JENKINS
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
HAYWOOD
Authorized Official Title or Position:
FOUNDER
Authorized Official Telephone Number:
617-419-0643

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  10031 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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