Healthcare Provider Details

I. General information

NPI: 1871427021
Provider Name (Legal Business Name): MOONPHASE INTEGRATIVE PSYCHIATRY & WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CABOT BLVD STE 300
MANSFIELD MA
02048-1183
US

IV. Provider business mailing address

235 MANCHAUG RD
SUTTON MA
01590-1647
US

V. Phone/Fax

Practice location:
  • Phone: 508-690-0688
  • Fax:
Mailing address:
  • Phone: 339-215-8115
  • 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: MICHELE WHITAKER
Title or Position: OWNER, MANAGING MBR
Credential: MSN, APRN,PMHNP-BC
Phone: 508-566-4032