Provider Demographics
NPI:1083503908
Name:BLACK EDEN WELLNESS LLC
Entity type:Organization
Organization Name:BLACK EDEN WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:GLAMARYS
Authorized Official - Middle Name:ELIANE
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, IBCLC
Authorized Official - Phone:510-542-9905
Mailing Address - Street 1:8401 MAYLAND DR STE A
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4648
Mailing Address - Country:US
Mailing Address - Phone:510-542-9905
Mailing Address - Fax:
Practice Address - Street 1:8401 MAYLAND DR STE A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4648
Practice Address - Country:US
Practice Address - Phone:510-542-9905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health