Healthcare Provider Details

I. General information

NPI: 1902654338
Provider Name (Legal Business Name): BALTIMORE ART THERAPY AND COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 LAKE AVE
BALTIMORE MD
21213-1034
US

IV. Provider business mailing address

8 THE GRN STE 8661
DOVER DE
19901-3618
US

V. Phone/Fax

Practice location:
  • Phone: 443-304-7137
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DARA GERVAIS GERVAIS
Title or Position: OWNER/DIRECTOR
Credential: LCPC
Phone: 443-304-7137