Provider Demographics
NPI:1497052930
Name:CLEGHORN PROFESSIONAL COUNSELING CENTER
Entity Type:Organization
Organization Name:CLEGHORN PROFESSIONAL COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:LMHC
Authorized Official - Phone:978-342-2709
Mailing Address - Street 1:63 FAIRMOUNT ST REAR
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-7613
Mailing Address - Country:US
Mailing Address - Phone:978-342-2709
Mailing Address - Fax:978-342-2709
Practice Address - Street 1:63 FAIRMOUNT ST REAR
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-7613
Practice Address - Country:US
Practice Address - Phone:978-342-2709
Practice Address - Fax:978-342-2709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0007433302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization