Basic Information
| Provider Information | |||||||||
| NPI: | 1083805402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLVINO | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.A., LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 NEWTON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017721215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084815500 | ||||||||
| FaxNumber: | 5084603025 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 NEWTON ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017721215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084815500 | ||||||||
| FaxNumber: | 5084603025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 08/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 5212 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.