Provider Demographics
NPI:1073077483
Name:WENTWORTH, MELISSA JANE (LMHC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EDINBURG CENTER, OPPORTUNITIES DAY TREATMENT
Mailing Address - Street 2:205 BURLINGTON ROAD
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730
Mailing Address - Country:US
Mailing Address - Phone:781-761-5209
Mailing Address - Fax:781-275-7205
Practice Address - Street 1:205 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1406
Practice Address - Country:US
Practice Address - Phone:781-761-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10007101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1004745OtherNHP
MA1303287OtherMBHP
MAM18633OtherBCBS
MA1004765OtherFALLON
MD1073617353OtherCCA
MA0000023532OtherBMC
MA042611055OtherTAX ID
MA99618201OtherNETWORK HELATH