Healthcare Provider Details

I. General information

NPI: 1083163307
Provider Name (Legal Business Name): CHESAPEAKE WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 S BOHEMIA AVE
CECILTON MD
21913-1010
US

IV. Provider business mailing address

79 PORT HERMAN RD
CHESAPEAKE CITY MD
21915-1633
US

V. Phone/Fax

Practice location:
  • Phone: 410-275-8156
  • Fax: 877-433-6830
Mailing address:
  • Phone: 410-275-8156
  • Fax: 877-433-6830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR177831
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberXK8322339
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberH0056426
License Number StateMD

VIII. Authorized Official

Name: LINDA JEAN KATZ
Title or Position: SOLE MEMBER
Credential:
Phone: 410-275-8156