Provider Demographics
NPI:1780031724
Name:WELLNESS SOURCE LLC
Entity Type:Organization
Organization Name:WELLNESS SOURCE LLC
Other - Org Name:YOUR WELLNESS SOURCES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALEE
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-235-0060
Mailing Address - Street 1:4301 GARDEN CITY DR STE 304
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-6105
Mailing Address - Country:US
Mailing Address - Phone:301-235-0600
Mailing Address - Fax:
Practice Address - Street 1:4301 GARDEN CITY DR STE 304
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-6105
Practice Address - Country:US
Practice Address - Phone:301-235-0060
Practice Address - Fax:240-324-7720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC051747821Medicaid
MD600082700Medicaid
MD540582OtherMEDICARE PTAN