Healthcare Provider Details

I. General information

NPI: 1205298148
Provider Name (Legal Business Name): WHITLEY WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2016
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 SHIPWAY PL # C-8
CHARLESTOWN MA
02129-4301
US

IV. Provider business mailing address

8 SHIPWAY PL # C-8
CHARLESTOWN MA
02129-4301
US

V. Phone/Fax

Practice location:
  • Phone: 325-439-9799
  • Fax: 617-987-9739
Mailing address:
  • Phone: 325-439-9799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRN2267850
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163WN1003X
TaxonomyNutrition Support Registered Nurse
License NumberRN2267850
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1099
License Number StateMA
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2267850
License Number StateMA
# 8
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GEOFFREY WHITLEY
Title or Position: OWNER
Credential: NP-C
Phone: 617-620-9757