Healthcare Provider Details

I. General information

NPI: 1114689023
Provider Name (Legal Business Name): BOSS WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 W LAKE MARY BLVD STE 208
LAKE MARY FL
32746-3460
US

IV. Provider business mailing address

1255 SAINT ALBANS LOOP
LAKE MARY FL
32746-1979
US

V. Phone/Fax

Practice location:
  • Phone: 407-308-0122
  • Fax: 407-264-6348
Mailing address:
  • Phone: 407-308-0122
  • Fax: 407-264-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHANTALA M BOSS
Title or Position: OWNER
Credential: LMHC
Phone: 407-308-0122