Provider Demographics
NPI:1013158310
Name:EXPRESSIVE THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:EXPRESSIVE THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:NALIBOTSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-838-4112
Mailing Address - Street 1:13153 BRUSHWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1025
Mailing Address - Country:US
Mailing Address - Phone:301-838-4112
Mailing Address - Fax:301-838-0623
Practice Address - Street 1:14808 PHYSICIANS LN STE 111
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3907
Practice Address - Country:US
Practice Address - Phone:301-838-4112
Practice Address - Fax:301-838-0623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03948103TC1900X
MD110571041C0700X
MD126811041C0700X
MDMFC 26055106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty