=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659618619
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LG WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2013
-----------------------------------------------------
Last Update Date | 01/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 WARREN RD SUITE 3A
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21208-5334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-591-7724
-----------------------------------------------------
Fax | 877-376-1801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6902 WALLIS AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21215-1709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-591-7724
-----------------------------------------------------
Fax | 877-376-1801
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAURA R GREER
-----------------------------------------------------
Credential | LCSW-C
-----------------------------------------------------
Telephone | 410-591-7724
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 09360
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------