Provider Demographics
NPI:1972924371
Name:INTENTIONAL SELF. LLC
Entity Type:Organization
Organization Name:INTENTIONAL SELF. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RANGE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:781-767-0008
Mailing Address - Street 1:141 MEMORIAL PKWY
Mailing Address - Street 2:PMB 211
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4511
Mailing Address - Country:US
Mailing Address - Phone:781-767-0008
Mailing Address - Fax:
Practice Address - Street 1:6 CABOT PL
Practice Address - Street 2:SUITE # 6
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-4625
Practice Address - Country:US
Practice Address - Phone:781-767-0008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5509251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health