Provider Demographics
NPI:1083336580
Name:ETW THERAPEUTIC & HOLISTIC SERVICES LLC
Entity Type:Organization
Organization Name:ETW THERAPEUTIC & HOLISTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-824-1480
Mailing Address - Street 1:7206 SHOCKLEY CT
Mailing Address - Street 2:
Mailing Address - City:FT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-1711
Mailing Address - Country:US
Mailing Address - Phone:410-824-1480
Mailing Address - Fax:410-824-1482
Practice Address - Street 1:10903 INDIAN HEAD HWY STE 404
Practice Address - Street 2:
Practice Address - City:FT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4019
Practice Address - Country:US
Practice Address - Phone:410-824-1480
Practice Address - Fax:410-824-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD555991000Medicaid