Provider Demographics
NPI:1760145734
Name:RESTORATIVE LIFE THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:RESTORATIVE LIFE THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:KANISHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW, LCSW-C
Authorized Official - Phone:443-743-2563
Mailing Address - Street 1:10530 CAMPUS WAY S # 1118
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1309
Mailing Address - Country:US
Mailing Address - Phone:443-743-2563
Mailing Address - Fax:
Practice Address - Street 1:2908 MUESERBUSH CT
Practice Address - Street 2:
Practice Address - City:GLENARDEN
Practice Address - State:MD
Practice Address - Zip Code:20706-5514
Practice Address - Country:US
Practice Address - Phone:443-743-2563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-18
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD734503800Medicaid