Provider Demographics
NPI:1851348536
Name:MARYLAND WELLNESS LLC
Entity Type:Organization
Organization Name:MARYLAND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPECIAL PROJECTS
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-241-6317
Mailing Address - Street 1:4128 HAYWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4340
Mailing Address - Country:US
Mailing Address - Phone:410-241-6317
Mailing Address - Fax:
Practice Address - Street 1:4200 FORBES BLVD
Practice Address - Street 2:STE 104
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4342
Practice Address - Country:US
Practice Address - Phone:301-429-6100
Practice Address - Fax:301-429-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415169102Medicaid
MD415169100Medicaid
MD415169101Medicaid
MD415169102Medicaid