Provider Demographics
NPI:1457894628
Name:PSYCHE1001 LEARN GROW CHANGE LLC
Entity Type:Organization
Organization Name:PSYCHE1001 LEARN GROW CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCNICOL
Authorized Official - Suffix:
Authorized Official - Credentials:APRNCNS BC
Authorized Official - Phone:508-636-4769
Mailing Address - Street 1:638 ADAMSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:MA
Mailing Address - Zip Code:02790-5031
Mailing Address - Country:US
Mailing Address - Phone:508-636-4769
Mailing Address - Fax:508-636-6463
Practice Address - Street 1:638 ADAMSVILLE RD
Practice Address - Street 2:SUITE 1001
Practice Address - City:WESTPORT
Practice Address - State:MA
Practice Address - Zip Code:02790-5031
Practice Address - Country:US
Practice Address - Phone:508-636-4769
Practice Address - Fax:508-636-6463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN00561364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Single Specialty