Healthcare Provider Details

I. General information

NPI: 1891311718
Provider Name (Legal Business Name): PRISM INTEGRATIVE HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8030 WOODMONT AVE FL 3
BETHESDA MD
20814-3027
US

IV. Provider business mailing address

8030 WOODMONT AVE FL 3
BETHESDA MD
20814-3027
US

V. Phone/Fax

Practice location:
  • Phone: 301-651-0303
  • Fax:
Mailing address:
  • Phone: 202-213-4829
  • 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
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SASHA BERGERON
Title or Position: CO-FOUNDER
Credential: NP
Phone: 202-213-4829