Provider Demographics
NPI:1972006104
Name:ATHINA-ELENI G. MAVROUDHIS, LMHC, INC.
Entity Type:Organization
Organization Name:ATHINA-ELENI G. MAVROUDHIS, LMHC, INC.
Other - Org Name:ATHINA-ELENI G. MAVROUDHIS, LMHC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:ATHINA-ELENI
Authorized Official - Middle Name:GOUDANAS
Authorized Official - Last Name:MAVROUDHIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:781-690-6635
Mailing Address - Street 1:23 WIGHT ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02452-7941
Mailing Address - Country:US
Mailing Address - Phone:781-690-6635
Mailing Address - Fax:978-313-8209
Practice Address - Street 1:23 WIGHT ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-7941
Practice Address - Country:US
Practice Address - Phone:781-690-6635
Practice Address - Fax:978-313-8209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6639251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health