Basic Information
| Provider Information | |||||||||
| NPI: | 1083163307 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHESAPEAKE WELLNESS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 PORT HERMAN RD | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219151633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102758156 | ||||||||
| FaxNumber: | 8774336830 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 S BOHEMIA AVE | ||||||||
| Address2: | |||||||||
| City: | CECILTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 219131010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102758156 | ||||||||
| FaxNumber: | 8774336830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 12/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4102758156 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | XK8322339 | MD | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 363LF0000X | R177831 | MD | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207QA0401X | H0056426 | MD | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
No ID Information.