Basic Information
| Provider Information | |||||||||
| NPI: | 1457786808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HABIT OPCO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2257 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137333488 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2257 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137333488 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2013 | ||||||||
| LastUpdateDate: | 09/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | MELENDEZ | ||||||||
| AuthorizedOfficialFirstName: | TEODORO | ||||||||
| AuthorizedOfficialMiddleName: | CARMELO | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4137333488 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | B.S., M.ED. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.