Healthcare Provider Details

I. General information

NPI: 1033846860
Provider Name (Legal Business Name): AZ'UELS COMMUNITY CONNECTIONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 SNYDER AVE
DUNDALK MD
21222-1713
US

IV. Provider business mailing address

1975 SNYDER AVE
DUNDALK MD
21222-1713
US

V. Phone/Fax

Practice location:
  • Phone: 240-583-0428
  • Fax:
Mailing address:
  • Phone: 240-583-0428
  • 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 Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MINI'IMAH WILSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW
Phone: 240-583-0428