Basic Information
| Provider Information | |||||||||
| NPI: | 1316654460 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHMG CORELIFE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1099 WINTERSON RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LINTHICUM HEIGHTS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210902279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009053261 | ||||||||
| FaxNumber: | 4438365606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1036 SAINT NICHOLAS DR UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206034758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2402617170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2022 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TEAGUE | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT /CEO | ||||||||
| AuthorizedOfficialTelephone: | 4105358240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 2084B0002X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Bariatric Medicine | 363LP0808X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 1041C0700X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.