Healthcare Provider Details

I. General information

NPI: 1346772712
Provider Name (Legal Business Name): BRIGHT HORIZONS BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 JOH AVE SUITE 180
BALTIMORE MD
21227-1137
US

IV. Provider business mailing address

PO BOX 1212
COLUMBIA MD
21044-0212
US

V. Phone/Fax

Practice location:
  • Phone: 571-288-3314
  • Fax: 888-760-4333
Mailing address:
  • Phone: 571-288-3314
  • Fax: 888-760-4333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: SANDRA MARTIN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 571-288-3314