Healthcare Provider Details

I. General information

NPI: 1699444810
Provider Name (Legal Business Name): SANATIVE COUNSELING AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 PAGE STREET
STOUTGHTON MA
02072
US

IV. Provider business mailing address

532 PAGE STREET
STOUTGHTON MA
02072
US

V. Phone/Fax

Practice location:
  • Phone: 508-960-1263
  • Fax: 339-364-2600
Mailing address:
  • Phone: 508-960-1263
  • Fax: 339-364-2600

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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH PETILLO
Title or Position: OWNER
Credential: LMHC
Phone: 508-960-1263