Provider Demographics
NPI:1851695662
Name:GOLGOTHA TOUCH BEHAVIORAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:GOLGOTHA TOUCH BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LILIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:240-731-0457
Mailing Address - Street 1:604 S FREDERICK AVE
Mailing Address - Street 2:211
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1275
Mailing Address - Country:US
Mailing Address - Phone:240-731-0457
Mailing Address - Fax:
Practice Address - Street 1:604 S FREDERICK AVE
Practice Address - Street 2:211
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1275
Practice Address - Country:US
Practice Address - Phone:240-731-0457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-08
Last Update Date:2011-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD155291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty