Healthcare Provider Details

I. General information

NPI: 1982273785
Provider Name (Legal Business Name): LUMINOUS VITALITY BEHAVIORAL HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FEDERAL ST STE 1900
BOSTON MA
02110-1861
US

IV. Provider business mailing address

100 RANDALL RD UNIT 1046
WRENTHAM MA
02093-7052
US

V. Phone/Fax

Practice location:
  • Phone: 617-841-3620
  • Fax: 617-334-5505
Mailing address:
  • Phone: 617-841-3620
  • Fax: 617-334-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: RONALD LEE
Title or Position: MANAGER
Credential: MD
Phone: 617-841-3620