Healthcare Provider Details

I. General information

NPI: 1316464951
Provider Name (Legal Business Name): LIFES ENERGY WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8737 BROOKS DR
EASTON MD
21601
US

IV. Provider business mailing address

8737 BROOKS DR STE 108
EASTON MD
21601-7474
US

V. Phone/Fax

Practice location:
  • Phone: 443-496-0245
  • Fax:
Mailing address:
  • Phone: 800-867-2395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberBH000195
License Number StateMD
# 8
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberBH00095
License Number StateMD
# 9
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberBH000195
License Number StateMD

VIII. Authorized Official

Name: MRS. ANDREA MARIA KELLEY-FREEMAN
Title or Position: CEO
Credential: LCADC, LGPC
Phone: 800-867-2395