Provider Demographics
NPI:1295585214
Name:MARYLAND WELLNESS PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:MARYLAND WELLNESS PSYCHOTHERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:MACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-661-1375
Mailing Address - Street 1:6005 BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ECHO
Mailing Address - State:MD
Mailing Address - Zip Code:20812-1101
Mailing Address - Country:US
Mailing Address - Phone:301-661-1375
Mailing Address - Fax:
Practice Address - Street 1:110 N WASHINGTON ST STE 200-15
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-2223
Practice Address - Country:US
Practice Address - Phone:301-661-1375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1407021777Medicaid