Basic Information
| Provider Information | |||||||||
| NPI: | 1558908830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OMNI PSYCHOTHERAPY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 714 MAIN ST UNIT 714-C | ||||||||
| Address2: | |||||||||
| City: | YARMOUTH PORT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026752000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178693740 | ||||||||
| FaxNumber: | 8332816727 | ||||||||
| Practice Location | |||||||||
| Address1: | 714 MAIN ST UNIT 714-C | ||||||||
| Address2: | |||||||||
| City: | YARMOUTH PORT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026752000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178693740 | ||||||||
| FaxNumber: | 8332816727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2019 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6178693740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LICSW | ||||||||
| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.