Provider Demographics
NPI:1427176874
Name:REAL WORLD MENTAL WELLNESS CENTER, P.C.
Entity type:Organization
Organization Name:REAL WORLD MENTAL WELLNESS CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SEARS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-713-8070
Mailing Address - Street 1:9458 W FAIRVIEW AVE STE J
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9785
Mailing Address - Country:US
Mailing Address - Phone:208-713-8070
Mailing Address - Fax:208-362-2010
Practice Address - Street 1:9458 W FAIRVIEW AVE STE J
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9785
Practice Address - Country:US
Practice Address - Phone:208-713-8070
Practice Address - Fax:208-362-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID10801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1691465Medicare ID - Type Unspecified