Healthcare Provider Details

I. General information

NPI: 1114633617
Provider Name (Legal Business Name): PUSH HEALTH AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 01/27/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 MOUNT HERMON RD # C-1
SALISBURY MD
21804-5302
US

IV. Provider business mailing address

1321 MOUNT HERMON RD # C-1
SALISBURY MD
21804-5302
US

V. Phone/Fax

Practice location:
  • Phone: 443-736-8691
  • Fax:
Mailing address:
  • Phone:
  • 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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. KENNETH T COLLINS
Title or Position: CO-OWNER
Credential:
Phone: 443-690-8029