Provider Demographics
NPI:1841554300
Name:THE WELLNESS ROOM
Entity type:Organization
Organization Name:THE WELLNESS ROOM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:HAVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FYFE-KIERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:617-775-5373
Mailing Address - Street 1:39 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02461-1436
Mailing Address - Country:US
Mailing Address - Phone:617-775-5373
Mailing Address - Fax:
Practice Address - Street 1:288 WALNUT ST STE 220
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02460-1994
Practice Address - Country:US
Practice Address - Phone:617-775-5373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA114084251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health