Provider Demographics
NPI:1619657640
Name:MODERN WELLNESS COUNSELING PC
Entity Type:Organization
Organization Name:MODERN WELLNESS COUNSELING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MELLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:339-237-0334
Mailing Address - Street 1:1112 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339-1675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1112 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339-1675
Practice Address - Country:US
Practice Address - Phone:339-237-0334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty