=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790679504
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEVATE MENTAL WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2025
-----------------------------------------------------
Last Update Date | 06/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 MAIN ST STE D
-----------------------------------------------------
City | REISTERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21136-1297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-205-5390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21163-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-205-5390
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. MARCUS WHITEHEAD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-205-5390
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------