Healthcare Provider Details

I. General information

NPI: 1649046814
Provider Name (Legal Business Name): CHARM CITY WELLNESS COLLABORATIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 SAINT DUNSTANS RD
BALTIMORE MD
21212-3736
US

IV. Provider business mailing address

5835 YORK RD # 1073
BALTIMORE MD
21212-3612
US

V. Phone/Fax

Practice location:
  • Phone: 443-377-3237
  • Fax: 410-226-7037
Mailing address:
  • Phone: 410-456-6315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MK HABER
Title or Position: FOUNDER, LEAD CLINICIAN
Credential: NP, IBCLC
Phone: 410-456-6315