Healthcare Provider Details

I. General information

NPI: 1316413222
Provider Name (Legal Business Name): PAIN & WELLNESS THERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 GARRISON BLVD STE 200
BALTIMORE MD
21216-2309
US

IV. Provider business mailing address

PO BOX 688
JESSUP MD
20794-0688
US

V. Phone/Fax

Practice location:
  • Phone: 301-592-7642
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. LESLIE OGBEBOR
Title or Position: NURSE PRACTITIONER
Credential: AGACNP-BC
Phone: 301-592-7642