Healthcare Provider Details

I. General information

NPI: 1750216669
Provider Name (Legal Business Name): WAYNE ETHIER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 BOYLSTON ST 5TH FLOOR
BOSTON MA
02116
US

IV. Provider business mailing address

PO BOX 880981
PORT ST LUCIE FL
34988-0981
US

V. Phone/Fax

Practice location:
  • Phone: 508-422-0404
  • Fax: 857-578-1200
Mailing address:
  • Phone: 508-422-0404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: WAYNE T ETHIER
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 508-422-0404