Provider Demographics
NPI:1013561976
Name:EQUANIMITY INTEGRATED BEHAVIORAL HEALTH & WELLNESS LLC
Entity Type:Organization
Organization Name:EQUANIMITY INTEGRATED BEHAVIORAL HEALTH & WELLNESS LLC
Other - Org Name:EQUANIMITY: IBHW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEGRAFENREID
Authorized Official - Suffix:II
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:410-240-1162
Mailing Address - Street 1:7500 HARFORD RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-6900
Mailing Address - Country:US
Mailing Address - Phone:410-240-1162
Mailing Address - Fax:
Practice Address - Street 1:7500 HARFORD RD STE 1
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-6900
Practice Address - Country:US
Practice Address - Phone:410-240-1162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-30
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty