Provider Demographics
NPI:1609163450
Name:THE BODY IMAGE THERAPY CENTER LLC
Entity Type:Organization
Organization Name:THE BODY IMAGE THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:WALEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:443-602-6515
Mailing Address - Street 1:8940 OLD ANNAPOLIS RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2129
Mailing Address - Country:US
Mailing Address - Phone:443-602-6515
Mailing Address - Fax:443-546-1100
Practice Address - Street 1:8940 OLD ANNAPOLIS RD
Practice Address - Street 2:SUITE E
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2129
Practice Address - Country:US
Practice Address - Phone:443-602-6515
Practice Address - Fax:443-546-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3911101YP2500X
MD152451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty