Provider Demographics
NPI:1225424005
Name:WOMEN'S INNERFITNESS & WELLNESS CENTER
Entity Type:Organization
Organization Name:WOMEN'S INNERFITNESS & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARAY
Authorized Official - Middle Name:IMANI
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:443-569-8882
Mailing Address - Street 1:2110 PRIEST BRIDGE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2472
Mailing Address - Country:US
Mailing Address - Phone:443-569-8882
Mailing Address - Fax:
Practice Address - Street 1:2110 PRIEST BRIDGE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2472
Practice Address - Country:US
Practice Address - Phone:443-569-8882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05442103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD07944490Medicaid
MD07944490Medicaid