Provider Demographics
NPI:1881230407
Name:LAUSELL-RODRIGUEZ, EVAN (MA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:LAUSELL-RODRIGUEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 FAIRBANKS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-4721
Practice Address - Country:US
Practice Address - Phone:845-219-6701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA13566101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health