Provider Demographics
NPI:1104590785
Name:COMPLETE WELLNESS BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:COMPLETE WELLNESS BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ESELLE
Authorized Official - Middle Name:MATHIAS
Authorized Official - Last Name:MOLUA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:240-643-5232
Mailing Address - Street 1:7112 SANDOWN CIR APT 303
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-7928
Mailing Address - Country:US
Mailing Address - Phone:240-643-5232
Mailing Address - Fax:
Practice Address - Street 1:7112 SANDOWN CIR APT 303
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-7928
Practice Address - Country:US
Practice Address - Phone:240-643-5232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4Medicaid