Provider Demographics
NPI:1083244354
Name:PLATINUM BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:PLATINUM BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:240-353-1018
Mailing Address - Street 1:2019 S ANVIL LN
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-4286
Mailing Address - Country:US
Mailing Address - Phone:240-353-1018
Mailing Address - Fax:
Practice Address - Street 1:1125 WEST ST STE 235
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-4198
Practice Address - Country:US
Practice Address - Phone:240-353-1018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-24
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD15880647208Medicaid