Healthcare Provider Details

I. General information

NPI: 1982035994
Provider Name (Legal Business Name): BODY IMAGE THERAPY CENTER INTENSIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2639 CONNECTICUT AVE NW STE 251
WASHINGTON DC
20008-2651
US

IV. Provider business mailing address

2639 CONNECTICUT AVE NW STE 251
WASHINGTON DC
20008-2651
US

V. Phone/Fax

Practice location:
  • Phone: 877-674-2843
  • Fax:
Mailing address:
  • Phone: 240-722-1014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY REALS
Title or Position: OUTPATIENT OPERATIONS MANAGER
Credential:
Phone: 202-819-5000