Provider Demographics
NPI:1851158919
Name:LELOS, JUSTIN GREGORY
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GREGORY
Last Name:LELOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-2415
Mailing Address - Country:US
Mailing Address - Phone:781-405-0442
Mailing Address - Fax:
Practice Address - Street 1:110 BOSTON ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-1402
Practice Address - Country:US
Practice Address - Phone:781-405-0442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health