Healthcare Provider Details

I. General information

NPI: 1851033740
Provider Name (Legal Business Name): ONE SOURCE WELLNESS WORKS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W PENNSYLVANIA AVE STE 410
TOWSON MD
21204-5017
US

IV. Provider business mailing address

22 W PENNSYLVANIA AVE STE 410
TOWSON MD
21204-5017
US

V. Phone/Fax

Practice location:
  • Phone: 478-397-9624
  • Fax:
Mailing address:
  • Phone: 478-397-9624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1730415498
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: MAXWELL MANNING
Title or Position: CLINICAL DIRECTOR
Credential: LCSWC
Phone: 301-252-4392