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1780031724

NPI Code Detail

MEDICARE: WELLNESS SOURCE LLC

MEDICARE: WELLNESS SOURCE 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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist
3	2084P0800X	Psychiatry Physician
4	2084P0802X	Addiction Psychiatry Physician
5	261QP2300X	Primary Care Clinic/Center
6	363LF0000X	Family Nurse Practitioner

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	540582	OTHER	MD	MEDICARE PTAN

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780031724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS SOURCE LLC

Provider Business Mailing Address
First Line	:	4301 GARDEN CITY DR STE 304
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-6105
Country	:	US
Telephone Number	:	301-235-0600
Fax Number	:

Provider Business Practice Location Address
First Line	:	4301 GARDEN CITY DR STE 304
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-6105
Country	:	US
Telephone Number	:	301-235-0060
Fax Number	:	240-324-7720

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	MARSHALEE GEORGE
Credential	:
Telephone Number	:	301-235-0060

Provider Enumeration Date	:	05/19/2016
Last Update Date	:	03/08/2024

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Directions to “WELLNESS SOURCE LLC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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