Provider Demographics
NPI:1821136656
Name:VIVEIROS, RUSSELL (MHC,LM&FT, LADAC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:VIVEIROS
Suffix:
Gender:M
Credentials:MHC,LM&FT, LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MAIN ST
Mailing Address - Street 2:SUITE # 9
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-4725
Mailing Address - Country:US
Mailing Address - Phone:978-851-0180
Mailing Address - Fax:978-851-8621
Practice Address - Street 1:1501 MAIN ST
Practice Address - Street 2:SUITE # 9
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-4725
Practice Address - Country:US
Practice Address - Phone:978-851-0180
Practice Address - Fax:978-851-8621
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0280101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA273OtherADDICTIONS COUNSELOR
MA328OtherMFT
MA557OtherMENTAL HEALTH COUNSELOR
MA204025OtherSOCIAL WORKER