=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427764844
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ELYSIAN FIELDS OPTIMUM WELLNESS AND MENTAL HEALTH GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2023
-----------------------------------------------------
Last Update Date | 02/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3401 ELGIN AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21216-2605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-624-5037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14625 BALTIMORE AVE STE 244
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20707-4902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-226-9499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ARTHUR GRIFFIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-367-0708
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------