Provider Demographics
NPI:1578215737
Name:MAE WELLNESS
Entity Type:Organization
Organization Name:MAE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH-PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, LPC
Authorized Official - Phone:718-594-2040
Mailing Address - Street 1:1108 E MAIN ST STE 701
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-3534
Mailing Address - Country:US
Mailing Address - Phone:718-594-2040
Mailing Address - Fax:
Practice Address - Street 1:1108 E MAIN ST STE 701
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-3534
Practice Address - Country:US
Practice Address - Phone:718-594-2040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty