Healthcare Provider Details

I. General information

NPI: 1336948728
Provider Name (Legal Business Name): PREMIER WELLNESS HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N MAIN ST
BEL AIR MD
21014-3539
US

IV. Provider business mailing address

103 N MAIN ST
BEL AIR MD
21014-3539
US

V. Phone/Fax

Practice location:
  • Phone: 888-333-1345
  • Fax: 410-732-2025
Mailing address:
  • Phone: 888-333-1345
  • Fax: 410-732-2025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA DICARA
Title or Position: OWNER
Credential:
Phone: 888-653-3933