Provider Demographics
NPI:1386477636
Name:SUPREME MENTAL WELLNESS LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:SUPREME MENTAL WELLNESS LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLAKUNLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AYANWALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-486-1560
Mailing Address - Street 1:8222 SCHULTZ RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2607
Mailing Address - Country:US
Mailing Address - Phone:240-486-1560
Mailing Address - Fax:
Practice Address - Street 1:8222 SCHULTZ RD STE 102
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2607
Practice Address - Country:US
Practice Address - Phone:240-486-1560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty