Provider Demographics
NPI:1982035994
Name:BODY IMAGE THERAPY CENTER INTENSIVE
Entity Type:Organization
Organization Name:BODY IMAGE THERAPY CENTER INTENSIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OUTPATIENT OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:REALS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-819-5000
Mailing Address - Street 1:2639 CONNECTICUT AVE NW STE 251
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-2651
Mailing Address - Country:US
Mailing Address - Phone:240-722-1014
Mailing Address - Fax:
Practice Address - Street 1:2639 CONNECTICUT AVE NW STE 251
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-2651
Practice Address - Country:US
Practice Address - Phone:877-674-2843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE BODY IMAGE THERAPY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-02
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X, 1041C0700X, 133N00000X
133V00000X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty