MEDICARE: SUPREME MENTAL WELLNESS LIMITED LIABILITY COMPANY

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1386477636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME MENTAL WELLNESS LIMITED LIABILITY COMPANY

Provider Business Mailing Address
First Line	:	8222 SCHULTZ RD STE 102
Second Line	:
City	:	CLINTON
State	:	MD
Zip	:	20735-2607
Country	:	US
Telephone Number	:	240-486-1560
Fax Number	:

Provider Business Practice Location Address
First Line	:	8222 SCHULTZ RD STE 102
Second Line	:
City	:	CLINTON
State	:	MD
Zip	:	20735-2607
Country	:	US
Telephone Number	:	240-486-1560
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	OLAKUNLE AYANWALE
Credential	:
Telephone Number	:	240-486-1560

Provider Enumeration Date	:	08/22/2024
Last Update Date	:	08/22/2024

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