Healthcare Provider Details

I. General information

NPI: 1174120513
Provider Name (Legal Business Name): WELLS OF WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

993 SOUTH STREET APT, SUITE, FLOOR, ETC.
ROSLINDALE MA
02131
US

IV. Provider business mailing address

40 CHARME AVE
ROSLINDALE MA
02131-3113
US

V. Phone/Fax

Practice location:
  • Phone: 857-204-6773
  • Fax:
Mailing address:
  • Phone: 857-204-6773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: MISS JEANNETTA V MONTISSOL
Title or Position: CEO
Credential: LMHC
Phone: 857-204-6773