Healthcare Provider Details

I. General information

NPI: 1568234409
Provider Name (Legal Business Name): BEWELL COMMUNITY HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 KENTLANDS BLVD
GAITHERSBURG MD
20878-5446
US

IV. Provider business mailing address

267 KENTLANDS BLVD
GAITHERSBURG MD
20878-5446
US

V. Phone/Fax

Practice location:
  • Phone: 240-587-6886
  • Fax:
Mailing address:
  • Phone: 240-587-6886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: EMILY E PAVLICK
Title or Position: CFO
Credential: LCSW-C
Phone: 301-793-9915