Healthcare Provider Details

I. General information

NPI: 1639896608
Provider Name (Legal Business Name): STOUCKWELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 TREMONT PL
SOMERVILLE MA
02143-4113
US

IV. Provider business mailing address

PO BOX 293
SOMERVILLE MA
02143-0005
US

V. Phone/Fax

Practice location:
  • Phone: 301-802-2414
  • Fax:
Mailing address:
  • Phone: 301-802-2414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RACHEL STOUCK
Title or Position: OWNER
Credential: LICSW
Phone: 301-802-2414