Healthcare Provider Details

I. General information

NPI: 1235735200
Provider Name (Legal Business Name): WELLNESS FOR WOMAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 LYNNWOOD LN
WORCESTER MA
01609-1117
US

IV. Provider business mailing address

52 LYNNWOOD LN
WORCESTER MA
01609-1117
US

V. Phone/Fax

Practice location:
  • Phone: 508-963-0935
  • 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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1235438128
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: MANDI ROBINSON
Title or Position: OWNER
Credential: MSW, LICSW
Phone: 508-963-0935