Provider Demographics
NPI:1629364666
Name:THE EAGLES NEST FAMILY AND CHILDREN SERVICES LLC
Entity Type:Organization
Organization Name:THE EAGLES NEST FAMILY AND CHILDREN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-910-4797
Mailing Address - Street 1:4006 JEFFERY COURT
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-3073
Mailing Address - Country:US
Mailing Address - Phone:443-910-4797
Mailing Address - Fax:410-515-0443
Practice Address - Street 1:900 A SOUTH MAIN STREET
Practice Address - Street 2:SUITE 105
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014
Practice Address - Country:US
Practice Address - Phone:410-914-4012
Practice Address - Fax:410-914-4013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3588101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty