Healthcare Provider Details

I. General information

NPI: 1649066697
Provider Name (Legal Business Name): MARYLAND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 FRANKLIN AVE STE 306
BERLIN MD
21811-1238
US

IV. Provider business mailing address

4128 HAYWARD AVE STE W
BALTIMORE MD
21215-4340
US

V. Phone/Fax

Practice location:
  • Phone: 410-973-2525
  • Fax: 410-973-2527
Mailing address:
  • Phone: 410-314-1030
  • Fax: 410-314-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. SIERRA BURLEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 410-314-1030