Provider Demographics
NPI:1790211225
Name:CITYPSYCH WELLNESS, INC.
Entity Type:Organization
Organization Name:CITYPSYCH WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERAVI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:617-797-1746
Mailing Address - Street 1:333 LEE BURBANK HWY STE 2
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-4003
Mailing Address - Country:US
Mailing Address - Phone:617-242-1000
Mailing Address - Fax:617-242-1099
Practice Address - Street 1:333 LEE BURBANK HWY STE 2
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-4003
Practice Address - Country:US
Practice Address - Phone:617-242-1000
Practice Address - Fax:617-242-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110099933/BOtherMEDICAID