Provider Demographics
NPI:1225659600
Name:WANDERLUST THERAPEUTIC SERVICES, PLLC
Entity Type:Organization
Organization Name:WANDERLUST THERAPEUTIC SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MELBOURNE
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:LICSW
Authorized Official - Phone:978-483-0182
Mailing Address - Street 1:71 SPIT BROOK RD STE 407
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-5636
Mailing Address - Country:US
Mailing Address - Phone:978-483-0182
Mailing Address - Fax:603-589-4981
Practice Address - Street 1:71 SPIT BROOK RD STE 407
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-5636
Practice Address - Country:US
Practice Address - Phone:978-728-2388
Practice Address - Fax:603-589-4981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-27
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty