Provider Demographics
NPI:1396082657
Name:IMAGINE WELLNESS, LLC
Entity type:Organization
Organization Name:IMAGINE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WISSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LBA, BCBA
Authorized Official - Phone:443-741-2249
Mailing Address - Street 1:7909 BELGARO RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-1108
Mailing Address - Country:US
Mailing Address - Phone:443-741-2249
Mailing Address - Fax:301-725-4608
Practice Address - Street 1:7909 BELGARO RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-1108
Practice Address - Country:US
Practice Address - Phone:443-741-2249
Practice Address - Fax:301-725-4608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1-11-8182103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty