Provider Demographics
NPI:1235406265
Name:EMOTIONAL WELLNESS COUNSELING
Entity Type:Organization
Organization Name:EMOTIONAL WELLNESS COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCTAVOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MARYLAND 8/1/11
Authorized Official - Phone:443-895-4183
Mailing Address - Street 1:8508 LOCH RAVEN BLVD
Mailing Address - Street 2:SUITE I
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21286-2354
Mailing Address - Country:US
Mailing Address - Phone:443-895-4183
Mailing Address - Fax:443-895-4184
Practice Address - Street 1:8508 LOCH RAVEN BLVD
Practice Address - Street 2:SUITE I
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286-2354
Practice Address - Country:US
Practice Address - Phone:443-895-4183
Practice Address - Fax:443-895-4184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3272261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419542600Medicaid