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General NPI Number Information
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NPI Number | 1669043196
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Entity Type | Organization
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Legal Business Name | PSYCHOTHERAPY AND MENTAL WELLNESS GROUP PRACTICE, PLLC
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Dates
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Enumeration Date | 07/06/2021
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Last Update Date | 07/06/2021
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Provider Practice Location Address
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Address Line | 10 SAINT PAULS PL APT 1L
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City | BROOKLYN
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State | NY
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Zip | 11226-1363
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Country | US
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Telephone | 213-373-4484
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Fax |
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Provider Business Mailing Address
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Address Line | 10 SAINT PAULS PL APT 1L
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City | BROOKLYN
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State | NY
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Zip | 11226-1363
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Country | US
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Telephone | 213-373-4484
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST/CLINICAL DIR
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Name | DR. MELISSA BOUDIN
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Credential | PSY.D.
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Telephone | 213-373-4484
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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