Provider Demographics
NPI:1578197752
Name:NEW LIFE WELLNESS GROUP
Entity type:Organization
Organization Name:NEW LIFE WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/COO
Authorized Official - Prefix:
Authorized Official - First Name:LONETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-285-9846
Mailing Address - Street 1:23 RED HEARTH CT
Mailing Address - Street 2:
Mailing Address - City:HALETHORPE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-3833
Mailing Address - Country:US
Mailing Address - Phone:443-285-9846
Mailing Address - Fax:
Practice Address - Street 1:110 W MULBERRY ST STE 100
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-3606
Practice Address - Country:US
Practice Address - Phone:443-203-8555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-27
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD835005100Medicaid