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General NPI Number Information
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NPI Number | 1205339413
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Entity Type | Organization
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Legal Business Name | WELLNESS SOURCE LLC
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Dates
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Enumeration Date | 03/14/2018
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Last Update Date | 11/13/2020
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Provider Practice Location Address
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Address Line | 4301 GARDEN CITY DR STE 304
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City | HYATTSVILLE
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State | MD
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Zip | 20785-6105
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Country | US
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Telephone | 301-235-0060
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Fax |
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Provider Business Mailing Address
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Address Line | 6305 IVY LN STE 101
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City | GREENBELT
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State | MD
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Zip | 20770-6326
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Country | US
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Telephone | 301-235-0060
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MARSHALEE GEORGE
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Credential |
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Telephone | 301-235-0060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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