Provider Demographics
NPI:1063744613
Name:COUNSELING CONNECTION OF LEXINGTON
Entity type:Organization
Organization Name:COUNSELING CONNECTION OF LEXINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANTAL
Authorized Official - Middle Name:F
Authorized Official - Last Name:NOUVELLON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:781-363-0390
Mailing Address - Street 1:2 WINTER ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451
Mailing Address - Country:US
Mailing Address - Phone:781-363-0390
Mailing Address - Fax:781-646-0509
Practice Address - Street 1:2 WINTER ST
Practice Address - Street 2:SUITE 401
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451
Practice Address - Country:US
Practice Address - Phone:781-363-0390
Practice Address - Fax:781-646-0509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1545832084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAG63595Medicare UPIN
MAA23289Medicare PIN