Healthcare Provider Details

I. General information

NPI: 1023609179
Provider Name (Legal Business Name): RBG WELLNESS SPACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 LAKESIDE AVE
BALTIMORE MD
21218-3001
US

IV. Provider business mailing address

1206 LAKESIDE AVE
BALTIMORE MD
21218-3001
US

V. Phone/Fax

Practice location:
  • Phone: 847-770-7477
  • Fax:
Mailing address:
  • Phone: 847-770-7477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: AISHA JEAN-BAPTISTE
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW-C
Phone: 847-770-7477