Provider Demographics
NPI:1912401183
Name:4 2 RESTORE, LLC
Entity Type:Organization
Organization Name:4 2 RESTORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM COORDINATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEADRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:443-500-4887
Mailing Address - Street 1:3527 N ROLLING RD STE 4
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2256
Mailing Address - Country:US
Mailing Address - Phone:443-500-4887
Mailing Address - Fax:
Practice Address - Street 1:8310 LIBERTY RD STE 2C
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-3124
Practice Address - Country:US
Practice Address - Phone:443-500-4887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-21
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health