Provider Demographics
NPI:1477253862
Name:BLACKWATER WELLNESS, LLC
Entity Type:Organization
Organization Name:BLACKWATER WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSON CUMBERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP-PMH
Authorized Official - Phone:443-521-6656
Mailing Address - Street 1:2855 CROCHERON RD
Mailing Address - Street 2:
Mailing Address - City:CROCHERON
Mailing Address - State:MD
Mailing Address - Zip Code:21627-1201
Mailing Address - Country:US
Mailing Address - Phone:443-521-6656
Mailing Address - Fax:
Practice Address - Street 1:7 CEDAR ST STE 3
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2381
Practice Address - Country:US
Practice Address - Phone:443-521-6656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty