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1205339413

NPI Code Detail

MEDICARE: WELLNESS SOURCE LLC

MEDICARE: WELLNESS SOURCE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205339413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS SOURCE LLC

Provider Business Mailing Address
First Line	:	6305 IVY LN STE 101
Second Line	:
City	:	GREENBELT
State	:	MD
Zip	:	20770-6326
Country	:	US
Telephone Number	:	301-235-0060
Fax Number	:

Provider Business Practice Location Address
First Line	:	4301 GARDEN CITY DR STE 304
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-6105
Country	:	US
Telephone Number	:	301-235-0060
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	MARSHALEE GEORGE
Credential	:
Telephone Number	:	301-235-0060

Provider Enumeration Date	:	03/14/2018
Last Update Date	:	11/13/2020

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Directions to “WELLNESS SOURCE LLC ” Practice Location

Language	Start Address	Practice Location

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