Basic Information
| Provider Information | |||||||||
| NPI: | 1982273785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUMINOUS VITALITY BEHAVIORAL HEALTH PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 RANDALL RD UNIT 1046 | ||||||||
| Address2: | |||||||||
| City: | WRENTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020937052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178413620 | ||||||||
| FaxNumber: | 6173345505 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 FEDERAL ST STE 1900 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021101861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178413620 | ||||||||
| FaxNumber: | 6173345505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2021 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6178413620 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.