Provider Demographics
NPI:1881260263
Name:LIFE OF ABUNDANCE BEHAVIORAL HEALTH SERVICES LLC
Entity type:Organization
Organization Name:LIFE OF ABUNDANCE BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:EJIM
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-731-2349
Mailing Address - Street 1:6918 RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237
Mailing Address - Country:US
Mailing Address - Phone:443-721-7574
Mailing Address - Fax:
Practice Address - Street 1:6918 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-3854
Practice Address - Country:US
Practice Address - Phone:443-731-2349
Practice Address - Fax:443-874-1347
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE OF ABUNDANCE PRP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-27
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health