Provider Demographics
NPI:1396392452
Name:STAYWELL BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:STAYWELL BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WATFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:410-569-4165
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-0028
Mailing Address - Country:US
Mailing Address - Phone:410-569-4165
Mailing Address - Fax:
Practice Address - Street 1:10451 MILL RUN CIR STE 400
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5594
Practice Address - Country:US
Practice Address - Phone:443-525-1495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty