Provider Demographics
NPI:1265040653
Name:BEHAVIORAL HEALTH AND THERAPY CLINIC
Entity Type:Organization
Organization Name:BEHAVIORAL HEALTH AND THERAPY CLINIC
Other - Org Name:BEHAVIORAL HEALTH AND THERAPY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:AMAOBI
Authorized Official - Middle Name:HARDY
Authorized Official - Last Name:AGBOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-693-2207
Mailing Address - Street 1:12501 PROSPERITY DR STE 330
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1655
Mailing Address - Country:US
Mailing Address - Phone:240-899-5315
Mailing Address - Fax:240-645-4013
Practice Address - Street 1:12501 PROSPERITY DR STE 330
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1655
Practice Address - Country:US
Practice Address - Phone:240-899-5315
Practice Address - Fax:240-645-4013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD852082721Medicaid