=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275852097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTE FOR SEXUAL WELLNESS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2010
-----------------------------------------------------
Last Update Date | 03/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1233 HANCOCK ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02169-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-479-4501
-----------------------------------------------------
Fax | 617-479-8109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1233 HANCOCK ST REAR
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02169-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-479-4501
-----------------------------------------------------
Fax | 617-479-8109
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. RENEE MARIE SORRENTINO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 617-479-4501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 102L00000X
-----------------------------------------------------
Taxonomy Name | Psychoanalyst
-----------------------------------------------------
License Number | 207842
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------