Provider Demographics
NPI:1912760877
Name:ADDICTION WELLNESS CENTER LLC
Entity type:Organization
Organization Name:ADDICTION WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-839-6928
Mailing Address - Street 1:5438 SANDY HILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:QUANTICO
Mailing Address - State:MD
Mailing Address - Zip Code:21856-2100
Mailing Address - Country:US
Mailing Address - Phone:443-547-2964
Mailing Address - Fax:
Practice Address - Street 1:5438 SANDY HILL RD STE A
Practice Address - Street 2:
Practice Address - City:QUANTICO
Practice Address - State:MD
Practice Address - Zip Code:21856-2100
Practice Address - Country:US
Practice Address - Phone:443-547-2964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADDICTION WELLNESS CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-02
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD213477200Medicaid