Healthcare Provider Details

I. General information

NPI: 1497413413
Provider Name (Legal Business Name): LIFES ENERGY WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 12/07/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 POPLAR ST
CAMBRIDGE MD
21613-1834
US

IV. Provider business mailing address

514 POPLAR ST
CAMBRIDGE MD
21613-1834
US

V. Phone/Fax

Practice location:
  • Phone: 800-867-2395
  • Fax: 410-443-0842
Mailing address:
  • Phone: 800-867-2395
  • Fax: 410-443-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANDREA MARIA KELLEY-FREEMAN
Title or Position: CEO
Credential:
Phone: 800-867-2395