Provider Demographics
NPI:1164124269
Name:COLLABORATIVE CARE & WELLNESS LLC
Entity Type:Organization
Organization Name:COLLABORATIVE CARE & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:410-245-0210
Mailing Address - Street 1:700 SUMMERTIME DR
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1590
Mailing Address - Country:US
Mailing Address - Phone:410-245-0210
Mailing Address - Fax:
Practice Address - Street 1:8028 RITCHIE HWY STE 104
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-1020
Practice Address - Country:US
Practice Address - Phone:410-245-0210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty