Provider Demographics
NPI:1134664394
Name:WELLNESS THERAPIST, LLC
Entity type:Organization
Organization Name:WELLNESS THERAPIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:YLIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PIMENTEL DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:617-299-9615
Mailing Address - Street 1:PO BOX 490849
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-0015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:264 BEACON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-1236
Practice Address - Country:US
Practice Address - Phone:617-299-9615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1189301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty