Provider Demographics
NPI:1023609179
Name:RBG WELLNESS SPACE, LLC
Entity type:Organization
Organization Name:RBG WELLNESS SPACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:AISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN-BAPTISTE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:847-770-7477
Mailing Address - Street 1:1206 LAKESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-3001
Mailing Address - Country:US
Mailing Address - Phone:847-770-7477
Mailing Address - Fax:
Practice Address - Street 1:1206 LAKESIDE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-3001
Practice Address - Country:US
Practice Address - Phone:847-770-7477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-01
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty