Provider Demographics
NPI:1083239255
Name:CERVELLO-WELLNESS, LLC
Entity Type:Organization
Organization Name:CERVELLO-WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-392-7120
Mailing Address - Street 1:4014 DIAMONDHEAD AVE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1308
Mailing Address - Country:US
Mailing Address - Phone:301-828-5239
Mailing Address - Fax:
Practice Address - Street 1:11810 GRAND PARK AVE STE 500
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-8679
Practice Address - Country:US
Practice Address - Phone:301-392-7120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-12
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD521090900Medicaid