Healthcare Provider Details

I. General information

NPI: 1568097673
Provider Name (Legal Business Name): IDENTITY AND MENTAL HEALTH PROJECT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 ROSSMORE RD APT 2L
BOSTON MA
02130-3671
US

IV. Provider business mailing address

65 ROSSMORE RD APT 2L
BOSTON MA
02130-3671
US

V. Phone/Fax

Practice location:
  • Phone: 857-453-8249
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE RANELLI
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LICSW
Phone: 413-687-2709