Healthcare Provider Details

I. General information

NPI: 1053275693
Provider Name (Legal Business Name): NEW LEAF BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 MAIN ST
WALTHAM MA
02451-0633
US

IV. Provider business mailing address

681 MAIN ST
WALTHAM MA
02451-0633
US

V. Phone/Fax

Practice location:
  • Phone: 508-371-8503
  • Fax:
Mailing address:
  • Phone: 508-371-8503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROSETTE WAKANABO
Title or Position: OWNER/ DIRECTOR
Credential: DR.
Phone: 508-371-8503