Provider Demographics
NPI:1548533789
Name:COMMONWEALTH MENTAL HEALTH & WELLNESS CENTER
Entity type:Organization
Organization Name:COMMONWEALTH MENTAL HEALTH & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:617-282-9772
Mailing Address - Street 1:35 BURT ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3705
Mailing Address - Country:US
Mailing Address - Phone:617-282-9772
Mailing Address - Fax:617-506-1573
Practice Address - Street 1:35 BURT ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-3705
Practice Address - Country:US
Practice Address - Phone:617-282-9772
Practice Address - Fax:617-506-1573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA572251S00000X
MA7173101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty