Basic Information
| Provider Information | |||||||||
| NPI: | 1932445186 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY COUNCIL OF NASHUA NH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RESEARCH CENTER AT GREATER NASHUA MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038896147 | ||||||||
| FaxNumber: | 6038831568 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038896147 | ||||||||
| FaxNumber: | 6038831568 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2012 | ||||||||
| LastUpdateDate: | 12/17/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAFEZ | ||||||||
| AuthorizedOfficialFirstName: | HISHAM | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6038896147 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY COUNCIL OF NASHUA NH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 30D0995846 | NH | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 30D0995846 | 01 | NH | CLIA | OTHER |