Provider Demographics
NPI:1508012816
Name:WELLLIFE NETWORK INC
Entity Type:Organization
Organization Name:WELLLIFE NETWORK INC
Other - Org Name:PSCH INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-559-0534
Mailing Address - Street 1:14202 20TH AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11351-3000
Mailing Address - Country:US
Mailing Address - Phone:718-559-0516
Mailing Address - Fax:718-762-6140
Practice Address - Street 1:40 ELMONT ROAD
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-1603
Practice Address - Country:US
Practice Address - Phone:347-542-5667
Practice Address - Fax:347-542-5840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01304109Medicaid