Provider Demographics
NPI:1316654460
Name:CHMG CORELIFE, LLC
Entity type:Organization
Organization Name:CHMG CORELIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEITHAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-535-8236
Mailing Address - Street 1:1099 WINTERSON RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2279
Mailing Address - Country:US
Mailing Address - Phone:800-905-3261
Mailing Address - Fax:443-836-5606
Practice Address - Street 1:1036 SAINT NICHOLAS DR UNIT 101
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4758
Practice Address - Country:US
Practice Address - Phone:240-261-7170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No2084B0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyObesity MedicineGroup - Single Specialty