Provider Demographics
NPI:1982273785
Name:LUMINOUS VITALITY BEHAVIORAL HEALTH PLLC
Entity Type:Organization
Organization Name:LUMINOUS VITALITY BEHAVIORAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-841-3620
Mailing Address - Street 1:100 RANDALL RD UNIT 1046
Mailing Address - Street 2:
Mailing Address - City:WRENTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02093-7052
Mailing Address - Country:US
Mailing Address - Phone:617-841-3620
Mailing Address - Fax:617-334-5505
Practice Address - Street 1:101 FEDERAL ST STE 1900
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-1861
Practice Address - Country:US
Practice Address - Phone:617-841-3620
Practice Address - Fax:617-334-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty