Provider Demographics
NPI:1255049441
Name:DOROTHY E MBELLASON
Entity type:Organization
Organization Name:DOROTHY E MBELLASON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:E
Authorized Official - Last Name:MBELLASON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:301-602-1526
Mailing Address - Street 1:12000 WEATHERVANE LN
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-5015
Mailing Address - Country:US
Mailing Address - Phone:301-602-1526
Mailing Address - Fax:
Practice Address - Street 1:12000 WEATHERVANE LN
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-5015
Practice Address - Country:US
Practice Address - Phone:301-602-1526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty