Provider Demographics
NPI:1467961805
Name:FAMILY THERAPY BEHAVIOR SERVICES, LLC
Entity Type:Organization
Organization Name:FAMILY THERAPY BEHAVIOR SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE EJIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-483-7358
Mailing Address - Street 1:3240 BELAIR RD STE B2ND
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-1228
Mailing Address - Country:US
Mailing Address - Phone:410-483-7358
Mailing Address - Fax:
Practice Address - Street 1:3240 BELAIR RD STE B2ND
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1228
Practice Address - Country:US
Practice Address - Phone:410-483-7358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health