Healthcare Provider Details

I. General information

NPI: 1467962605
Provider Name (Legal Business Name): THE HEARTWOOD PROGRAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 EAST WEST HWY STE 1025
BETHESDA MD
20814-4520
US

IV. Provider business mailing address

4350 EAST WEST HWY STE 201
BETHESDA MD
20814-4492
US

V. Phone/Fax

Practice location:
  • Phone: 301-970-4099
  • Fax: 301-970-4098
Mailing address:
  • Phone: 301-970-4099
  • Fax: 301-970-4098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KURT KOCHES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 301-970-4011