Provider Demographics
NPI:1902141179
Name:EAST SIDE COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:EAST SIDE COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:508-567-1477
Mailing Address - Street 1:1311 BEDFORD ST.
Mailing Address - Street 2:
Mailing Address - City:FALL RIVE, MA
Mailing Address - State:MA
Mailing Address - Zip Code:02723
Mailing Address - Country:US
Mailing Address - Phone:508-567-1477
Mailing Address - Fax:598-567-6494
Practice Address - Street 1:1311 BEDFORD ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-2637
Practice Address - Country:US
Practice Address - Phone:508-567-1477
Practice Address - Fax:508-567-6494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10284381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA002028201Medicare PIN