Healthcare Provider Details

I. General information

NPI: 1306755475
Provider Name (Legal Business Name): MAKE ROOM PSYCHIATRY & WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNION PL STE 104
DEDHAM MA
02026-4437
US

IV. Provider business mailing address

1 UNION PL STE 104
DEDHAM MA
02026-4437
US

V. Phone/Fax

Practice location:
  • Phone: 617-223-7183
  • Fax:
Mailing address:
  • Phone: 617-223-7183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SOPHIA MONTISSOL
Title or Position: MANAGING MEMBER
Credential: PMHNP-BC
Phone: 617-223-7183