Provider Demographics
NPI:1235773193
Name:LIFE OF ABUNDANCE BEHAVIORAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:LIFE OF ABUNDANCE BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:EJIM
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-721-7574
Mailing Address - Street 1:1281 SUGARWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:MD
Mailing Address - Zip Code:21221-5447
Mailing Address - Country:US
Mailing Address - Phone:443-721-7574
Mailing Address - Fax:
Practice Address - Street 1:7544 HOLABIRD AVE
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2104
Practice Address - Country:US
Practice Address - Phone:443-721-7574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-04
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Single Specialty