Healthcare Provider Details

I. General information

NPI: 1003504481
Provider Name (Legal Business Name): WELLMIND LICENSED CLINICAL SOCIAL WORKER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 GENG RD STE 210
PALO ALTO CA
94303-3307
US

IV. Provider business mailing address

2100 GENG RD STE 210
PALO ALTO CA
94303-3307
US

V. Phone/Fax

Practice location:
  • Phone: 833-646-3243
  • Fax:
Mailing address:
  • Phone: 833-646-3243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA BEANN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 833-646-3243