Basic Information
| Provider Information | |||||||||
| NPI: | 1457488967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AZORA-MINDA | ||||||||
| FirstName: | BODEN | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 ERDMAN WAY | ||||||||
| Address2: | |||||||||
| City: | LEOMINSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014531804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784668330 | ||||||||
| FaxNumber: | 9785373496 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | LEOMINSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014533361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784668330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 09/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 101Y00000X | 01 | MA | COUNSELOR | OTHER |