MEDICARE: MARYLAND WELLNESS 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1215510193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARYLAND WELLNESS LLC

Provider Business Mailing Address
First Line	:	4128 HAYWARD AVE # W
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-4340
Country	:	US
Telephone Number	:	410-241-6317
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 E MAIN ST # 101
Second Line	:
City	:	WESTMINSTER
State	:	MD
Zip	:	21157-5012
Country	:	US
Telephone Number	:	410-241-6317
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CASEY WU
Credential	:
Telephone Number	:	410-241-6317

Provider Enumeration Date	:	04/29/2021
Last Update Date	:	04/29/2021

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Directions to “MARYLAND WELLNESS LLC ” Practice Location

Language	Start Address	Practice Location

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