Provider Demographics
NPI:1730723701
Name:PARK WELLNESS GROUP LLC
Entity type:Organization
Organization Name:PARK WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOOT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSWC
Authorized Official - Phone:803-493-5657
Mailing Address - Street 1:508 LIKESTON CT
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-1722
Mailing Address - Country:US
Mailing Address - Phone:803-493-5657
Mailing Address - Fax:
Practice Address - Street 1:517 BENFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2527
Practice Address - Country:US
Practice Address - Phone:410-216-4421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-03
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty