MEDICARE: ADVANTIA MENTAL WELLNESS 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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1720564594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTIA MENTAL WELLNESS LLC

Provider Business Mailing Address
First Line	:	1525 WILSON BLVD STE 540
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22209-2444
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 FOREST GLEN RD STE 500
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-1467
Country	:	US
Telephone Number	:	301-273-6611
Fax Number	:

Authorized Official
Title or Position	:	CMO
Name	:	PETER GLASS
Credential	:	MD
Telephone Number	:	631-496-6120

Provider Enumeration Date	:	07/16/2018
Last Update Date	:	07/16/2018

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