| One Alkaline Life, Llc | |
|
1036 Saint Nicholas Dr Unit 102 Waldorf MD 20603-4758 | |
| (410) 934-0580 | |
| (410) 834-1217 |
| Full Name | One Alkaline Life, Llc |
|---|---|
| Speciality | Counselor |
| Location | 1036 Saint Nicholas Dr Unit 102, Waldorf, Maryland |
| Authorized Official Name and Position | Lester Stevens (CEO) |
| Authorized Official Contact | 4109340581 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| One Alkaline Life, Llc 5800 Betsy Cir Waldorf MD 20601-3301 Ph: (410) 934-0580 | One Alkaline Life, Llc 1036 Saint Nicholas Dr Unit 102 Waldorf MD 20603-4758 Ph: (410) 934-0580 |
| NPI Number | 1104572775 |
|---|---|
| Provider Enumeration Date | 02/23/2022 |
| Last Update Date | 05/15/2024 |
| Certification Date | 05/15/2024 |
| Medicare PECOS PAC ID | 9638541568 |
|---|---|
| Medicare Enrollment ID | O20230202000964 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1104572775 | NPI | - | NPPES |
| 317218000 | Medicaid | MD |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| Provider Name | Gillian Kemba Gregory |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1174877484 PECOS PAC ID: 6608240619 Enrollment ID: I20230314002398 |
| Provider Name | Sharita Alise Sivels |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1326412826 PECOS PAC ID: 9335581693 Enrollment ID: I20240531002349 |
| Provider Name | Tammy Lavette Mackins-hill |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1063840940 PECOS PAC ID: 6709256647 Enrollment ID: I20240612000250 |
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