Provider Demographics
NPI:1629508171
Name:FRESH START PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:FRESH START PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:GREEN
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:978-222-9818
Mailing Address - Street 1:18 RAILROAD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-3570
Mailing Address - Country:US
Mailing Address - Phone:978-222-9818
Mailing Address - Fax:978-824-9475
Practice Address - Street 1:18 RAILROAD ST STE 1
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3570
Practice Address - Country:US
Practice Address - Phone:978-222-9818
Practice Address - Fax:978-824-9475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7734103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1821363615OtherNPI