Provider Demographics
NPI:1225612278
Name:THERACONNEX LLC
Entity Type:Organization
Organization Name:THERACONNEX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JALESA
Authorized Official - Middle Name:JANAY
Authorized Official - Last Name:FRYE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:508-596-6022
Mailing Address - Street 1:138 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4142
Mailing Address - Country:US
Mailing Address - Phone:508-596-6022
Mailing Address - Fax:
Practice Address - Street 1:138 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4142
Practice Address - Country:US
Practice Address - Phone:508-596-6022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)