=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649066697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYLAND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2025
-----------------------------------------------------
Last Update Date | 04/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 314 FRANKLIN AVE STE 306
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21811-1238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-973-2525
-----------------------------------------------------
Fax | 410-973-2527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4128 HAYWARD AVE STE W
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21215-4340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-314-1030
-----------------------------------------------------
Fax | 410-314-1030
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | MS. SIERRA BURLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-314-1030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------