Provider Demographics
NPI:1326052317
Name:PSYCHOLOGICAL ASSOCIATES OF SOUTHEASTERN MASSACHUSETTS, LLC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL ASSOCIATES OF SOUTHEASTERN MASSACHUSETTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:508-238-7766
Mailing Address - Street 1:115 MAIN ST
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1468
Mailing Address - Country:US
Mailing Address - Phone:508-238-7766
Mailing Address - Fax:508-230-5089
Practice Address - Street 1:115 MAIN ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1468
Practice Address - Country:US
Practice Address - Phone:508-238-7766
Practice Address - Fax:508-230-5089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA99999103TC0700X, 1041C0700X
MA99999992084P0800X
MAXXXXXXX364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9785442Medicaid
MAM20575OtherBC/BS OF MASSACHUSETTS
MA170367000OtherMAGELLAN BEHAVIORAL HEALT
MA665748OtherTUFTS HEALTH PLAN
MAM20575OtherBC/BS OF MASSACHUSETTS
MA9785442Medicaid