Healthcare Provider Details

I. General information

NPI: 1467225581
Provider Name (Legal Business Name): TOTAL WELLNESS MENTAL HEALTH CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 HIGHCREST CT
MANCHESTER MD
21102-1413
US

IV. Provider business mailing address

2504 HIGHCREST CT
MANCHESTER MD
21102-1413
US

V. Phone/Fax

Practice location:
  • Phone: 443-895-0898
  • Fax:
Mailing address:
  • Phone: 443-895-0898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA EKWUTIFE
Title or Position: PRESIDENT
Credential:
Phone: 443-895-0898