Provider Demographics
NPI:1417517939
Name:SYNERGY WELLNESS THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:SYNERGY WELLNESS THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEIDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SORRELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:240-300-3525
Mailing Address - Street 1:11260 HESS CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-4961
Mailing Address - Country:US
Mailing Address - Phone:240-300-3525
Mailing Address - Fax:240-523-8425
Practice Address - Street 1:3195 OLD WASHINGTON RD # 227
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3201
Practice Address - Country:US
Practice Address - Phone:240-461-1305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD441231100Medicaid