Provider Demographics
NPI:1225852072
Name:GATHERING TANK
Entity type:Organization
Organization Name:GATHERING TANK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUILLEMIN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:607-701-6073
Mailing Address - Street 1:42 LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-6148
Mailing Address - Country:US
Mailing Address - Phone:617-701-6073
Mailing Address - Fax:
Practice Address - Street 1:42 LOWELL RD
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-6148
Practice Address - Country:US
Practice Address - Phone:617-701-6073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty