Provider Demographics
NPI:1669043196
Name:PSYCHOTHERAPY AND MENTAL WELLNESS GROUP PRACTICE, PLLC
Entity Type:Organization
Organization Name:PSYCHOTHERAPY AND MENTAL WELLNESS GROUP PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/CLINICAL DIR
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:213-373-4484
Mailing Address - Street 1:10 SAINT PAULS PL APT 1L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-1363
Mailing Address - Country:US
Mailing Address - Phone:213-373-4484
Mailing Address - Fax:
Practice Address - Street 1:10 SAINT PAULS PL APT 1L
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-1363
Practice Address - Country:US
Practice Address - Phone:213-373-4484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health