Healthcare Provider Details

I. General information

NPI: 1003418989
Provider Name (Legal Business Name): EMPAS WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2020
Last Update Date: 11/15/2020
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7213 CHAPPARAL DR
DISTRICT HEIGHTS MD
20747-1772
US

IV. Provider business mailing address

4244 SUITLAND RD APT 103
SUITLAND MD
20746-2054
US

V. Phone/Fax

Practice location:
  • Phone: 301-388-6086
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CHARLES SMALLEY
Title or Position: OWNER
Credential:
Phone: 301-388-6086