Provider Demographics
NPI:1184093221
Name:CHARM CITY MENTAL HEALTH PRACTICE, LLC
Entity type:Organization
Organization Name:CHARM CITY MENTAL HEALTH PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/RESIDENT AGENT
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:COURTNEY
Authorized Official - Last Name:MATYJA
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-927-6535
Mailing Address - Street 1:100 WEST RD STE 112
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2358
Mailing Address - Country:US
Mailing Address - Phone:443-927-6535
Mailing Address - Fax:410-828-0300
Practice Address - Street 1:100 WEST RD STE 112
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2358
Practice Address - Country:US
Practice Address - Phone:443-927-6535
Practice Address - Fax:410-828-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-18
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6058261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC6058OtherLICENSED CLINICAL PROFESSIONAL COUNSELOR