MEDICARE: PSYCHWELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1952870792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHWELLNESS, LLC

Provider Business Mailing Address
First Line	:	85 STOCURRO DR
Second Line	:
City	:	HARPSWELL
State	:	ME
Zip	:	04079-3051
Country	:	US
Telephone Number	:	207-749-0018
Fax Number	:

Provider Business Practice Location Address
First Line	:	169 PARK ROW STE 6
Second Line	:
City	:	BRUNSWICK
State	:	ME
Zip	:	04011-2039
Country	:	US
Telephone Number	:	207-547-5023
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VICKY M PACKARD
Credential	:	APRN
Telephone Number	:	207-749-0018

Provider Enumeration Date	:	11/23/2018
Last Update Date	:	11/23/2018

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