Healthcare Provider Details

I. General information

NPI: 1508794207
Provider Name (Legal Business Name): WELLNESS SOURCE PSYCHOTHERAPY AND CONSULTING, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 BONITA AVE 2ND FL
BERKELEY CA
94704
US

IV. Provider business mailing address

2930 DOMINGO AVE # 1167
BERKELEY CA
94705-2454
US

V. Phone/Fax

Practice location:
  • Phone: 510-826-3150
  • Fax:
Mailing address:
  • Phone: 510-826-3150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. OMAR ANTHONY BOCOBO
Title or Position: PRESIDENT/OWNER
Credential: LCSW
Phone: 510-826-3150