Provider Demographics
NPI:1477165868
Name:MD MC SPROUT 1 LLC
Entity Type:Organization
Organization Name:MD MC SPROUT 1 LLC
Other - Org Name:SPROUT THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGHEB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-210-8200
Mailing Address - Street 1:7761 DIAMONDBACK RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-3240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7761 DIAMONDBACK RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-3240
Practice Address - Country:US
Practice Address - Phone:301-265-3520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty