Healthcare Provider Details

I. General information

NPI: 1538640057
Provider Name (Legal Business Name): HEFUNA MENTAL HEALTH WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 W 7TH ST STE 200
FREDERICK MD
21701-4106
US

IV. Provider business mailing address

7474 GREENWAY CENTER DR STE 700A
GREENBELT MD
20770-3523
US

V. Phone/Fax

Practice location:
  • Phone: 301-245-6300
  • Fax:
Mailing address:
  • Phone: 301-982-3437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD66576
License Number StateMD

VIII. Authorized Official

Name: CAROLYN REIDY
Title or Position: MANGER
Credential:
Phone: 845-590-3230