MEDICARE: MODERN WELLNESS COUNSELING PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1619657640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN WELLNESS COUNSELING PC

Provider Business Mailing Address
First Line	:	1112 WASHINGTON ST
Second Line	:
City	:	HANOVER
State	:	MA
Zip	:	02339-1675
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1112 WASHINGTON ST
Second Line	:
City	:	HANOVER
State	:	MA
Zip	:	02339-1675
Country	:	US
Telephone Number	:	339-237-0334
Fax Number	:

Authorized Official
Title or Position	:	LMHC/OWNER
Name	:	LISA MELLACE
Credential	:
Telephone Number	:	339-237-0334

Provider Enumeration Date	:	07/24/2023
Last Update Date	:	05/07/2024

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