Provider Demographics
NPI:1518399187
Name:INSIGHTFUL LIFE THERAPEUTIC SERVICES LLC
Entity Type:Organization
Organization Name:INSIGHTFUL LIFE THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NWOGWUGWU
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LCADC
Authorized Official - Phone:443-722-1649
Mailing Address - Street 1:575 S CHARLES ST STE 140
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-2477
Mailing Address - Country:US
Mailing Address - Phone:443-873-7197
Mailing Address - Fax:
Practice Address - Street 1:575 S CHARLES ST STE 140
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-2477
Practice Address - Country:US
Practice Address - Phone:443-873-7197
Practice Address - Fax:443-873-7198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4438251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMH-60Medicaid