=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154716686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A WELL PLACE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2015
-----------------------------------------------------
Last Update Date | 06/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 VENUS DR.
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-556-7781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 VENUS DR
-----------------------------------------------------
City | WORCESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-556-7781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALYSSA WYMAN PACIFIC
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 781-264-1441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 116094
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------