Healthcare Provider Details

I. General information

NPI: 1639951403
Provider Name (Legal Business Name): WELLNANCE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730A S WATERSIDE DR
LANEXA VA
23089-6132
US

IV. Provider business mailing address

1730A S WATERSIDE DR
LANEXA VA
23089-6132
US

V. Phone/Fax

Practice location:
  • Phone: 617-999-5680
  • Fax:
Mailing address:
  • Phone: 617-999-5680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DESIRE PETRIN
Title or Position: OWNER
Credential: LCSW
Phone: 617-999-5680