Provider Demographics
NPI:1114348463
Name:COMMUNITY WELLNESS OUTPATIENT MENTAL HEALTH CENTER LLC
Entity Type:Organization
Organization Name:COMMUNITY WELLNESS OUTPATIENT MENTAL HEALTH CENTER LLC
Other - Org Name:COMMUNITY WELLNESS OUTPATIENT MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MBA
Authorized Official - Phone:443-708-5056
Mailing Address - Street 1:3310 EASTERN AVENUE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-4108
Mailing Address - Country:US
Mailing Address - Phone:443-708-5056
Mailing Address - Fax:
Practice Address - Street 1:3310 EASTERN AVENUE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4108
Practice Address - Country:US
Practice Address - Phone:443-708-5056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-03
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD424340400Medicaid