Provider Demographics
NPI:1376087635
Name:PREMIER WELLNESS HEALTHCARE
Entity Type:Organization
Organization Name:PREMIER WELLNESS HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DICARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-333-1345
Mailing Address - Street 1:133 BLACK OAK TRL
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:PA
Mailing Address - Zip Code:17314-8756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-3539
Practice Address - Country:US
Practice Address - Phone:888-333-1345
Practice Address - Fax:888-653-0154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7635036-00Medicaid