Provider Demographics
NPI:1770255291
Name:HEALTH RELEAF LLC
Entity Type:Organization
Organization Name:HEALTH RELEAF LLC
Other - Org Name:SELF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOATMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-399-6874
Mailing Address - Street 1:1406B CRAIN HWY S STE 304
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4094
Mailing Address - Country:US
Mailing Address - Phone:301-804-0344
Mailing Address - Fax:
Practice Address - Street 1:1406B CRAIN HWY S STE 304
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4094
Practice Address - Country:US
Practice Address - Phone:301-804-0344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-03
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD633004500Medicaid