Healthcare Provider Details

I. General information

NPI: 1063307999
Provider Name (Legal Business Name): NORTHERN LIGHTS WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 07/04/2025
Certification Date: 07/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 RIVERDALE ST
WEST SPRINGFIELD MA
01089-4916
US

IV. Provider business mailing address

1321 RIVERDALE ST
WEST SPRINGFIELD MA
01089-4916
US

V. Phone/Fax

Practice location:
  • Phone: 469-684-4410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: HAYLEY PEPIN
Title or Position: CO-FOUNDER
Credential: LICSW
Phone: 469-684-4410