Provider Demographics
NPI:1114689023
Name:BOSS WELLNESS, LLC
Entity Type:Organization
Organization Name:BOSS WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANTALA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOSS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:407-308-0122
Mailing Address - Street 1:1255 SAINT ALBANS LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1979
Mailing Address - Country:US
Mailing Address - Phone:407-308-0122
Mailing Address - Fax:407-264-6348
Practice Address - Street 1:3551 W LAKE MARY BLVD STE 208
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3460
Practice Address - Country:US
Practice Address - Phone:407-308-0122
Practice Address - Fax:407-264-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health