Healthcare Provider Details

I. General information

NPI: 1730787847
Provider Name (Legal Business Name): ENVISION HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 W ROLLING XRDS STE 111
CATONSVILLE MD
21228-6211
US

IV. Provider business mailing address

5122 CREST HAVEN WAY PERRY HALL MD 21128
PERRY HALL MD
21128
US

V. Phone/Fax

Practice location:
  • Phone: 443-867-7471
  • Fax:
Mailing address:
  • Phone: 443-867-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTIE SIMON-WATERMAN
Title or Position: OWNER/ PROVIDER
Credential: CRNP
Phone: 443-867-7471