Provider Demographics
NPI:1508631839
Name:KINTSUGI PSYCHOTHERAPY
Entity Type:Organization
Organization Name:KINTSUGI PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLOWES
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:508-221-1224
Mailing Address - Street 1:194 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631-1037
Mailing Address - Country:US
Mailing Address - Phone:508-221-1224
Mailing Address - Fax:
Practice Address - Street 1:411 ROUTE 6A BLDG 2
Practice Address - Street 2:
Practice Address - City:YARMOUTH PORT
Practice Address - State:MA
Practice Address - Zip Code:02675-1843
Practice Address - Country:US
Practice Address - Phone:508-221-1224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty