MEDICARE: THE WELLNESS ROOM

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	251S00000X	Community/Behavioral Health Agency	114084	MA

General Provider Information

NPI Number	:	1841554300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE WELLNESS ROOM

Provider Business Mailing Address
First Line	:	39 COLUMBUS ST
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02461-1436
Country	:	US
Telephone Number	:	617-775-5373
Fax Number	:

Provider Business Practice Location Address
First Line	:	288 WALNUT ST STE 220
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02460-1994
Country	:	US
Telephone Number	:	617-775-5373
Fax Number	:

Authorized Official
Title or Position	:	OWNER AND OPERATOR
Name	:	HAVEN FYFE-KIERNAN
Credential	:	LICSW
Telephone Number	:	617-775-5373

Provider Enumeration Date	:	06/29/2012
Last Update Date	:	06/29/2012

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Directions to “THE WELLNESS ROOM ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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