NPIMap

Organization Active NPI

Wellness Legacy LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Towson, MD
National Provider Identifier
1992433916
Registry record updated Mar 27, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X
Legal business name
WELLNESS LEGACY LLC
Practice address
1016 Dulaney Valley Rd
Towson, MD 21204-2702
Phone
(410) 286-1258
NPI assigned
Aug 9, 2022
Organization subpart
Yes
Parent organization
WELLNESS LEGACY LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 27, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mark Anthony Bergonia Ison, CRNP- PMHNPI 1881152783
Title
Co -Owner
Phone
(410) 286-1258

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X Primary

Addresses

Primary practice location

1016 Dulaney Valley Rd
Towson, MD 21204-2702

Mailing address

1539 Blakes Legacy Dr
Bel Air, MD 21014-1946
Phone (410) 286-1258

Other names 1

  • Wellness Legacy LLC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191122000371 MD Part B Supplier - Clinic/Group Practice 1052743457 Receives reassigned benefits from 7 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Towson, MD; Bel Air, MD

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Wellness Legacy LLC3 organizations share this tax ID, including this one
Part of
Wellness Legacy LLC

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

260 Gateway Dr
Ste 13B
Bel Air, MD 21014
Phone (410) 286-1258

1016 Dulaney Valley Rd
Towson, MD 21204
Phone (410) 286-1258

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1660003200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1711497600000",
    "number": "1992433916",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1539 BLAKES LEGACY DR",
            "city": "BEL AIR",
            "state": "MD",
            "postal_code": "210141946",
            "telephone_number": "410-286-1258",
            "fax_number": "443-231-3684"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1016 DULANEY VALLEY RD",
            "city": "TOWSON",
            "state": "MD",
            "postal_code": "212042702",
            "telephone_number": "410-286-1258"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLNESS LEGACY LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WELLNESS LEGACY LLC",
        "enumeration_date": "2022-08-09",
        "last_updated": "2024-03-27",
        "certification_date": "2024-03-27",
        "status": "A",
        "authorized_official_last_name": "ISON",
        "authorized_official_first_name": "MARK ANTHONY",
        "authorized_official_middle_name": "BERGONIA",
        "authorized_official_title_or_position": "CO -OWNER",
        "authorized_official_telephone_number": "410-286-1258",
        "authorized_official_credential": "CRNP- PMH"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wellness Legacy LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Towson, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 27, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.