Basic Information
| Provider Information | |||||||||
| NPI: | 1003000365 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NASHUA YOUTH COUNCIL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | THE YOUTH COUNCIL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 WEST PEARL STREET | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038891090 | ||||||||
| FaxNumber: | 6035981703 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 WEST PEARL STREET | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038891090 | ||||||||
| FaxNumber: | 6035981703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2007 | ||||||||
| LastUpdateDate: | 07/24/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOYLE | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIR OF QUALITY & COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 6038891090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 788015050NH | 01 | ANTHEM | OTHER |