Healthcare Provider Details

I. General information

NPI: 1316654460
Provider Name (Legal Business Name): CHMG CORELIFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1036 SAINT NICHOLAS DR UNIT 101
WALDORF MD
20603-4758
US

IV. Provider business mailing address

1099 WINTERSON RD STE 300
LINTHICUM HEIGHTS MD
21090-2279
US

V. Phone/Fax

Practice location:
  • Phone: 240-261-7170
  • Fax:
Mailing address:
  • Phone: 800-905-3261
  • Fax: 443-836-5606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084B0002X
TaxonomyObesity Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN HEITHAUS
Title or Position: CFO
Credential:
Phone: 410-535-8236