Provider Demographics
NPI:1386351815
Name:BRILLIANCE PSYCHIATRY AND WELLNESS
Entity type:Organization
Organization Name:BRILLIANCE PSYCHIATRY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PEARL
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, PMHNP-BC
Authorized Official - Phone:706-436-7101
Mailing Address - Street 1:1443 ROCK SPRING RD UNIT 190
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-1920
Mailing Address - Country:US
Mailing Address - Phone:443-767-4053
Mailing Address - Fax:
Practice Address - Street 1:1 OLYMPIC PL
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4104
Practice Address - Country:US
Practice Address - Phone:443-767-4053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-03
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty