Provider Demographics
NPI:1386271849
Name:PSYCHIATRY WELLNESS CENTER PA
Entity type:Organization
Organization Name:PSYCHIATRY WELLNESS CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TABORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-696-9272
Mailing Address - Street 1:6801 LAKE WORTH RD STE 213-214
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-2955
Mailing Address - Country:US
Mailing Address - Phone:561-444-2351
Mailing Address - Fax:561-469-7089
Practice Address - Street 1:6801 LAKE WORTH RD STE 213-214
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33467-2955
Practice Address - Country:US
Practice Address - Phone:561-444-2351
Practice Address - Fax:561-469-7089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-25
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107183900Medicaid