Healthcare Provider Details

I. General information

NPI: 1306303433
Provider Name (Legal Business Name): VITALITY HEALTH AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 APOLLO DR STE 100
LARGO MD
20774-4785
US

IV. Provider business mailing address

3638 SWEETBUSH TRL
LAUREL MD
20724-2492
US

V. Phone/Fax

Practice location:
  • Phone: 240-696-7796
  • Fax:
Mailing address:
  • Phone: 301-651-2588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DANA HUBBARD
Title or Position: ADMIN/CLINICAL MANAGER
Credential:
Phone: 301-651-2588