Provider Demographics
NPI:1740587179
Name:PREMIERE THERAPEUTIC SERVICES, LLC
Entity Type:Organization
Organization Name:PREMIERE THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JABIR
Authorized Official - Middle Name:NA'IM
Authorized Official - Last Name:PASHA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD-LCPC
Authorized Official - Phone:410-885-4500
Mailing Address - Street 1:2125 MARYLAND AVE
Mailing Address - Street 2:106
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5634
Mailing Address - Country:US
Mailing Address - Phone:410-885-4500
Mailing Address - Fax:410-982-0091
Practice Address - Street 1:5516 TODD AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-3721
Practice Address - Country:US
Practice Address - Phone:410-615-2931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2117101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0244686 00Medicaid
MD5542251Medicaid