Healthcare Provider Details

I. General information

NPI: 1457602708
Provider Name (Legal Business Name): NORTHEAST WELLNESS GROUP, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 FOREST AVE STE 14
PORTLAND ME
04101-2037
US

IV. Provider business mailing address

449 FOREST AVE STE 14
PORTLAND ME
04101-2037
US

V. Phone/Fax

Practice location:
  • Phone: 774-269-4700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH RILEY
Title or Position: CEO
Credential:
Phone: 774-269-4700