Healthcare Provider Details

I. General information

NPI: 1346499381
Provider Name (Legal Business Name): ALYSSA JAYNE WYMAN PACIFIC MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 VENUS DR
WORCESTER MA
01605-1013
US

IV. Provider business mailing address

23 VENUS DR
WORCESTER MA
01605-1013
US

V. Phone/Fax

Practice location:
  • Phone: 781-264-1441
  • Fax:
Mailing address:
  • Phone: 781-264-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116094
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberS20883105
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: