Healthcare Provider Details

I. General information

NPI: 1902303415
Provider Name (Legal Business Name): ELYSIAN FIELDS OPTIMUM WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 N HOWARD ST
BALTIMORE MD
21218
US

IV. Provider business mailing address

2222 N HOWARD ST
BALTIMORE MD
21218-5609
US

V. Phone/Fax

Practice location:
  • Phone: 410-624-5037
  • Fax:
Mailing address:
  • Phone: 410-624-5037
  • Fax: 800-405-6914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberBH000553
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ARTHUR GRIFFIN
Title or Position: OWNER
Credential:
Phone: 410-624-5037