MEDICARE: ADDICTION WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275203275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADDICTION WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	5438 SANDY HILL RD STE A
Second Line	:
City	:	QUANTICO
State	:	MD
Zip	:	21856-2100
Country	:	US
Telephone Number	:	443-547-2964
Fax Number	:

Provider Business Practice Location Address
First Line	:	5438 SANDY HILL RD STE A
Second Line	:
City	:	QUANTICO
State	:	MD
Zip	:	21856-2100
Country	:	US
Telephone Number	:	443-547-2964
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	JESSIE COSTLEY
Credential	:
Telephone Number	:	443-839-6928

Provider Enumeration Date	:	09/20/2021
Last Update Date	:	02/28/2025

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Directions to “ADDICTION WELLNESS CENTER LLC ” Practice Location

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