Healthcare Provider Details

I. General information

NPI: 1710832704
Provider Name (Legal Business Name): BLACK LIGHT THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 S BELNORD AVE
BALTIMORE MD
21224-3804
US

IV. Provider business mailing address

635 S BELNORD AVE
BALTIMORE MD
21224-3804
US

V. Phone/Fax

Practice location:
  • Phone: 425-876-2681
  • Fax:
Mailing address:
  • Phone: 425-876-2681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: RHONDA ELAINE MOORE
Title or Position: MANAGING MEMBER
Credential:
Phone: 425-876-2681