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General NPI Number Information
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NPI Number | 1942004262
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Entity Type | Organization
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Legal Business Name | CERVELLO-WELLNESS, LLC
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Dates
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Enumeration Date | 04/03/2025
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Last Update Date | 04/03/2025
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Provider Practice Location Address
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Address Line | 6010 EXECUTIVE BLVD STE 700
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City | ROCKVILLE
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State | MD
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Zip | 20852-3885
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Country | US
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Telephone | 301-392-7120
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Fax |
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Provider Business Mailing Address
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Address Line | 4014 DIAMONDHEAD AVE
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City | BOWIE
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State | MD
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Zip | 20721-1308
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Country | US
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Telephone | 301-828-5239
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MIMI TYSON
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Credential | NP
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Telephone | 301-828-5239
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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