Healthcare Provider Details

I. General information

NPI: 1023520764
Provider Name (Legal Business Name): LIFES ENERGY WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 POPLAR ST
CAMBRIDGE MD
21613-1834
US

IV. Provider business mailing address

8737 BROOKS DR STE 108
EASTON MD
21601-7474
US

V. Phone/Fax

Practice location:
  • Phone: 180-867-2395
  • Fax:
Mailing address:
  • Phone: 443-496-0245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCA2304
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA2304
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBH000384
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberLCA2304
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANDREA M KELLEY-FREEMAN
Title or Position: CEO
Credential: LCADC
Phone: 800-867-2395