Healthcare Provider Details

I. General information

NPI: 1548533789
Provider Name (Legal Business Name): COMMONWEALTH MENTAL HEALTH & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2012
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 BURT ST
DORCHESTER MA
02124-3705
US

IV. Provider business mailing address

35 BURT ST
DORCHESTER MA
02124-3705
US

V. Phone/Fax

Practice location:
  • Phone: 617-282-9772
  • Fax: 617-506-1573
Mailing address:
  • Phone: 617-282-9772
  • Fax: 617-506-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7173
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number572
License Number StateMA

VIII. Authorized Official

Name: MR. DAVID LEON AVERY
Title or Position: PRESIDENT/CEO
Credential: LMHC
Phone: 617-282-9772