| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 23 Wight St, Waltham, Massachusetts |
| Authorized Official Name and Position | Athina-eleni Goudanas Mavroudhis (PRESIDENT/CLINICIAN) |
| Authorized Official Contact | 7816906635 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
23 Wight St Waltham MA 02452-7941 Ph: (781) 690-6635 | 23 Wight St Waltham MA 02452-7941 Ph: (781) 690-6635 |
| NPI Number | 1972006104 |
|---|---|
| Provider Enumeration Date | 03/14/2018 |
| Last Update Date | 03/14/2018 |
| Medicare PECOS PAC ID | 9931642964 |
|---|---|
| Medicare Enrollment ID | O20240619000841 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972006104 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 6639 (Massachusetts) | Primary |
| Provider Name | Athina-eleni Goudanas Mavroodhis |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1578706826 PECOS PAC ID: 8325267453 Enrollment ID: I20240619000987 |
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