Provider Demographics
NPI:1710562889
Name:SELF AUTHENTICALLY FOREVER EVOLVING COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:SELF AUTHENTICALLY FOREVER EVOLVING COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, CAC-AD
Authorized Official - Phone:973-943-2455
Mailing Address - Street 1:6201 GREENBELT RD STE L4
Mailing Address - Street 2:
Mailing Address - City:BERWYN HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20740-2357
Mailing Address - Country:US
Mailing Address - Phone:240-965-7262
Mailing Address - Fax:240-553-7177
Practice Address - Street 1:6201 GREENBELT RD STE L4
Practice Address - Street 2:
Practice Address - City:BERWYN HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20740-2357
Practice Address - Country:US
Practice Address - Phone:240-965-7262
Practice Address - Fax:240-553-7177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty