Provider Demographics
NPI:1568177657
Name:ECLECTIC THERAPY COLLECTIVE, LLC
Entity Type:Organization
Organization Name:ECLECTIC THERAPY COLLECTIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-841-9502
Mailing Address - Street 1:396 WEST CT
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-4766
Mailing Address - Country:US
Mailing Address - Phone:443-841-9502
Mailing Address - Fax:
Practice Address - Street 1:396 WEST CT
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4766
Practice Address - Country:US
Practice Address - Phone:443-841-9502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-23
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty