Healthcare Provider Details

I. General information

NPI: 1255118022
Provider Name (Legal Business Name): MONTGOMERY WELLNESS HUB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 RUSSELL AVE STE D
GAITHERSBURG MD
20879-3283
US

IV. Provider business mailing address

951 RUSSELL AVE STE D
GAITHERSBURG MD
20879-3283
US

V. Phone/Fax

Practice location:
  • Phone: 301-404-7336
  • Fax: 240-246-7911
Mailing address:
  • Phone: 301-404-7336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMED KOLAWOLE IBRAHIM
Title or Position: CEO
Credential:
Phone: 240-246-7837