Provider Demographics
NPI:1235709817
Name:CORY COVE WELLNESS LLC
Entity Type:Organization
Organization Name:CORY COVE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDEXTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:774-432-3063
Mailing Address - Street 1:41 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-2035
Mailing Address - Country:US
Mailing Address - Phone:774-432-3063
Mailing Address - Fax:
Practice Address - Street 1:41 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01501-2035
Practice Address - Country:US
Practice Address - Phone:774-432-3063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1992084321Medicaid