Provider Demographics
NPI:1588372320
Name:ORIGINS WELLNESS GROUP
Entity type:Organization
Organization Name:ORIGINS WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:347-949-1044
Mailing Address - Street 1:1029 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01085-9711
Mailing Address - Country:US
Mailing Address - Phone:347-949-1044
Mailing Address - Fax:
Practice Address - Street 1:1029 NORTH RD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-9711
Practice Address - Country:US
Practice Address - Phone:347-949-1044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)