Provider Demographics
NPI:1235795733
Name:RESTORE YOU COUNSELING AND CONSULTATION, LLC
Entity Type:Organization
Organization Name:RESTORE YOU COUNSELING AND CONSULTATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANNING
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-254-9608
Mailing Address - Street 1:4812 CIRCLING HUNTER DR APT 202
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6401 PIONEER DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-1092
Practice Address - Country:US
Practice Address - Phone:410-564-6893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2011131Medicaid