Provider Demographics
NPI:1396631651
Name:EMBODIED WELLNESS COLLABORATIVE
Entity type:Organization
Organization Name:EMBODIED WELLNESS COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:WESTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:857-217-2181
Mailing Address - Street 1:14 PERKINS SQ APT 1
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1719
Mailing Address - Country:US
Mailing Address - Phone:857-217-2181
Mailing Address - Fax:
Practice Address - Street 1:14 PERKINS SQ APT 1
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1719
Practice Address - Country:US
Practice Address - Phone:857-217-2181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-14
Last Update Date:2025-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110221484AMedicaid