Provider Demographics
NPI:1487863494
Name:COUNSELING & ASSESSMENT CLINIC OF WORCESTER LLC
Entity Type:Organization
Organization Name:COUNSELING & ASSESSMENT CLINIC OF WORCESTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:J
Authorized Official - Last Name:HYLTON
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:508-756-5400
Mailing Address - Street 1:255 PARK AVE STE 804
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1984
Mailing Address - Country:US
Mailing Address - Phone:508-756-5400
Mailing Address - Fax:508-756-5433
Practice Address - Street 1:255 PARK AVE STE 804
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609
Practice Address - Country:US
Practice Address - Phone:508-756-5400
Practice Address - Fax:508-756-5433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TC0700X
MA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1894196Medicaid