Provider Demographics
NPI:1164990818
Name:PRIME BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:PRIME BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:FOMENGIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-463-3357
Mailing Address - Street 1:13994 BALTIMORE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13994 BALTIMORE AVE STE 102
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5087
Practice Address - Country:US
Practice Address - Phone:240-463-3357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-10
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)