Provider Demographics
NPI:1235723321
Name:MIND OVER MATTERX
Entity Type:Organization
Organization Name:MIND OVER MATTERX
Other - Org Name:MIND OVER MATTER RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:RAMALHO
Authorized Official - Last Name:GOULART
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:617-480-1371
Mailing Address - Street 1:80 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-0120
Mailing Address - Country:US
Mailing Address - Phone:617-480-1371
Mailing Address - Fax:
Practice Address - Street 1:80 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-0120
Practice Address - Country:US
Practice Address - Phone:617-480-1371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110105695AMedicaid