Provider Demographics
NPI:1093011413
Name:NATIONAL STRESS CLINIC, LLC
Entity Type:Organization
Organization Name:NATIONAL STRESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-571-8627
Mailing Address - Street 1:150 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-1828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 N ORANGE ST
Practice Address - Street 2:SUITE 600
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1155
Practice Address - Country:US
Practice Address - Phone:646-571-8627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005431103T00000X
MD03127103T00000X
WI2592-057103T00000X
HI1214103TC0700X
CAMFT (MFC) 376951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty