Healthcare Provider Details

I. General information

NPI: 1184183683
Provider Name (Legal Business Name): TRANSITION WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W ROE BLVD
PATCHOGUE NY
11772-2569
US

IV. Provider business mailing address

15 NEW MILL RD
SMITHTOWN NY
11787-3323
US

V. Phone/Fax

Practice location:
  • Phone: 631-493-7636
  • Fax:
Mailing address:
  • Phone: 631-493-7636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DIANE E WAHNE
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 631-493-7636