Provider Demographics
NPI:1417520529
Name:M & M MENTAL HEALTH AND WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:M & M MENTAL HEALTH AND WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:HALE
Authorized Official - Last Name:MAURO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP-PMH
Authorized Official - Phone:443-845-4269
Mailing Address - Street 1:122 WAELCHLI AVE
Mailing Address - Street 2:
Mailing Address - City:HALETHORPE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-2546
Mailing Address - Country:US
Mailing Address - Phone:443-845-4269
Mailing Address - Fax:
Practice Address - Street 1:122 WAELCHLI AVE
Practice Address - Street 2:
Practice Address - City:HALETHORPE
Practice Address - State:MD
Practice Address - Zip Code:21227-2546
Practice Address - Country:US
Practice Address - Phone:443-845-4269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1154915387Medicaid