Provider Demographics
NPI:1003479668
Name:MARYLAND WELLNESS LLC
Entity Type:Organization
Organization Name:MARYLAND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-659-1503
Mailing Address - Street 1:4128 HAYWARD AVE # W
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4340
Mailing Address - Country:US
Mailing Address - Phone:410-994-6491
Mailing Address - Fax:
Practice Address - Street 1:4128 HAYWARD AVE # W
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4340
Practice Address - Country:US
Practice Address - Phone:410-994-6491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
No251B00000XAgenciesCase Management
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD220412460OtherMARYLAND BEHAVIORAL HEALTH ADMINISTRATION
MD220412463OtherMARYLAND BEHAVIORAL HEALTH ADMINISTRATION
MD220412462OtherMARYLAND BEHAVIORAL HEALTH ADMINISTRATION
MD907713800Medicaid
MD220412461OtherMARYLAND BEHAVIORAL HEALTH ADMINISTRATION
MD220412464OtherMARYLAND BEHAVIORAL HEALTH ADMINISTRATION