Provider Demographics
NPI:1629861091
Name:MENTAL WELLNESS PSYCHIATRY
Entity type:Organization
Organization Name:MENTAL WELLNESS PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:FADIPE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:541-991-5501
Mailing Address - Street 1:2386 MORRIS AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-5723
Mailing Address - Country:US
Mailing Address - Phone:908-777-1617
Mailing Address - Fax:
Practice Address - Street 1:188 HUCKLEBERRY LN
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-8779
Practice Address - Country:US
Practice Address - Phone:541-991-5501
Practice Address - Fax:862-205-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty