Healthcare Provider Details

I. General information

NPI: 1366015455
Provider Name (Legal Business Name): LIFE ENHANCEMENT SERVICES OF MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 02/26/2023
Certification Date: 02/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 SECURITY BLVD STE 100
BALTIMORE MD
21207-5173
US

IV. Provider business mailing address

1818 NEW YORK AVE NE STE 115
WASHINGTON DC
20002-1851
US

V. Phone/Fax

Practice location:
  • Phone: 202-269-2401
  • Fax:
Mailing address:
  • Phone: 202-269-2401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. HERBERT GRAY III
Title or Position: CEO
Credential:
Phone: 202-269-2401