Healthcare Provider Details

I. General information

NPI: 1386477636
Provider Name (Legal Business Name): SUPREME MENTAL WELLNESS LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8222 SCHULTZ RD STE 102
CLINTON MD
20735-2607
US

IV. Provider business mailing address

8222 SCHULTZ RD STE 102
CLINTON MD
20735-2607
US

V. Phone/Fax

Practice location:
  • Phone: 240-486-1560
  • Fax:
Mailing address:
  • Phone: 240-486-1560
  • Fax:

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
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OLAKUNLE AYANWALE
Title or Position: PRESIDENT
Credential:
Phone: 240-486-1560