Provider Demographics
NPI:1659046936
Name:PROVIDENCE WELLNESS, LLC
Entity Type:Organization
Organization Name:PROVIDENCE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:KAROFF HUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:401-585-3729
Mailing Address - Street 1:669 PUBLIC ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-1640
Mailing Address - Country:US
Mailing Address - Phone:401-585-3729
Mailing Address - Fax:
Practice Address - Street 1:669 PUBLIC ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1640
Practice Address - Country:US
Practice Address - Phone:401-585-3729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)