Provider Demographics
NPI:1962121772
Name:432 INTENTIONAL THERAPEUTICS INC
Entity type:Organization
Organization Name:432 INTENTIONAL THERAPEUTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LOUISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:774-255-0635
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02541-0056
Mailing Address - Country:US
Mailing Address - Phone:774-255-0635
Mailing Address - Fax:
Practice Address - Street 1:400 NATHAN ELLIS HWY STE B
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-3121
Practice Address - Country:US
Practice Address - Phone:774-255-0635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)