Provider Demographics
NPI:1235723321
Name:MIND OVER MATTERX
Entity type:Organization
Organization Name:MIND OVER MATTERX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:MONIZ
Authorized Official - Last Name:GOULART
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:781-705-0567
Mailing Address - Street 1:607 NORTH AVE OFC 18
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1306
Mailing Address - Country:US
Mailing Address - Phone:781-705-0567
Mailing Address - Fax:
Practice Address - Street 1:607 NORTH AVE OFC 18
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1306
Practice Address - Country:US
Practice Address - Phone:781-705-0567
Practice Address - Fax:623-666-6792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110105695AMedicaid