Healthcare Provider Details

I. General information

NPI: 1467387811
Provider Name (Legal Business Name): ELITE SELF DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 LEONARDTOWN RD STE 201
WALDORF MD
20601-3697
US

IV. Provider business mailing address

9707 BIRD RIVER RD
MIDDLE RIVER MD
21220-1701
US

V. Phone/Fax

Practice location:
  • Phone: 443-850-2142
  • Fax:
Mailing address:
  • Phone: 443-850-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: GWENAE CARTER
Title or Position: CEO
Credential:
Phone: 410-846-2008