Provider Demographics
NPI:1871202929
Name:MBI WELLE, ELIZABETH WAKAI
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:WAKAI
Last Name:MBI WELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 STRETFORD WAY APT 101
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-5948
Mailing Address - Country:US
Mailing Address - Phone:301-532-6613
Mailing Address - Fax:
Practice Address - Street 1:7 KAFERN DR APT 2A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-4280
Practice Address - Country:US
Practice Address - Phone:301-532-6613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD104100000X
MDMD-10272598024172A00000X
251S00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No172A00000XOther Service ProvidersDriver
No251S00000XAgenciesCommunity/Behavioral Health