Healthcare Provider Details

I. General information

NPI: 1811486962
Provider Name (Legal Business Name): LIFES ENERGY WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8737 BROOKS DR STE 108 SUITE 108
EASTON MD
21601-7474
US

IV. Provider business mailing address

PO BOX 123
EASTON MD
21601-8901
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code364SH0200X
TaxonomyHome Health Clinical Nurse Specialist
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberBH000383
License Number StateMD

VIII. Authorized Official

Name: ANDREA KELLEY-FREEMAN
Title or Position: CEO
Credential:
Phone: 800-867-2395