Basic Information
| Provider Information | |||||||||
| NPI: | 1043654346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAKARUTSA | ||||||||
| FirstName: | GLANDAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 172 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NORTH CHELMSFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018631831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788667360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 77 E MERRIMACK ST | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018521251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9784536800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2013 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.