Provider Demographics
NPI:1518613264
Name:RESTORATIVE BEHAVIOR, LLC
Entity Type:Organization
Organization Name:RESTORATIVE BEHAVIOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:EBONIQUE
Authorized Official - Middle Name:KATRESS
Authorized Official - Last Name:MCCLINNAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, PMHNP-BC
Authorized Official - Phone:910-797-1491
Mailing Address - Street 1:9701 APOLLO DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4783
Mailing Address - Country:US
Mailing Address - Phone:301-798-6125
Mailing Address - Fax:301-355-0276
Practice Address - Street 1:9701 APOLLO DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-4783
Practice Address - Country:US
Practice Address - Phone:301-798-6125
Practice Address - Fax:301-355-0276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-22
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6660066.OtherAETNA