Provider Demographics
NPI:1386194611
Name:ACTIVATED BY WELLNESS, LLC
Entity type:Organization
Organization Name:ACTIVATED BY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:VIVIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN-HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:617-871-9807
Mailing Address - Street 1:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02346-0254
Mailing Address - Country:US
Mailing Address - Phone:617-871-9807
Mailing Address - Fax:617-419-1055
Practice Address - Street 1:66 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1012
Practice Address - Country:US
Practice Address - Phone:617-871-9807
Practice Address - Fax:617-419-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1197671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty