Healthcare Provider Details

I. General information

NPI: 1497287361
Provider Name (Legal Business Name): HOLISTIC HEALTH & WELLNESS MEDICAL SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 MERCANTILE LN 221
LARGO MD
20774-5376
US

IV. Provider business mailing address

1450 MERCANTILE LN 221
LARGO MD
20774-5376
US

V. Phone/Fax

Practice location:
  • Phone: 301-772-1500
  • Fax: 301-773-0050
Mailing address:
  • Phone: 301-772-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. JOYCE SHAWANDA EDWARDS
Title or Position: OWNER
Credential: OWNER
Phone: 301-772-1500