Healthcare Provider Details

I. General information

NPI: 1295498798
Provider Name (Legal Business Name): WELLESLEY COUNSELING AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MICA LN STE 205
WELLESLEY MA
02481-1708
US

IV. Provider business mailing address

14 MICA LN STE 205
WELLESLEY MA
02481-1708
US

V. Phone/Fax

Practice location:
  • Phone: 617-304-1057
  • Fax:
Mailing address:
  • Phone: 617-304-1057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: EMILY LANGE
Title or Position: CO-OWNER, CLINICIAN
Credential: LMHC, REAT
Phone: 617-304-1057