Provider Demographics
NPI:1316413222
Name:PAIN & WELLNESS THERAPIES LLC
Entity Type:Organization
Organization Name:PAIN & WELLNESS THERAPIES LLC
Other - Org Name:PAIN & WELLNESS THERAPIES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OGBEBOR
Authorized Official - Suffix:
Authorized Official - Credentials:AGACNP-BC
Authorized Official - Phone:301-592-7642
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:JESSUP
Mailing Address - State:MD
Mailing Address - Zip Code:20794-0688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 GARRISON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2309
Practice Address - Country:US
Practice Address - Phone:301-592-7642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-17
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1851637094Medicaid
MD1922502319Medicaid