Healthcare Provider Details

I. General information

NPI: 1376087635
Provider Name (Legal Business Name): PREMIER WELLNESS HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N MAIN ST
BEL AIR MD
21014-3539
US

IV. Provider business mailing address

133 BLACK OAK TRL
DELTA PA
17314-8756
US

V. Phone/Fax

Practice location:
  • Phone: 888-333-1345
  • Fax: 888-653-0154
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA DICARA
Title or Position: OWNER
Credential:
Phone: 888-333-1345