Healthcare Provider Details

I. General information

NPI: 1104773399
Provider Name (Legal Business Name): GREEN VALLEY THERAPY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 SAINT PAUL ST STE 2
BOONSBORO MD
21713-1334
US

IV. Provider business mailing address

9 SAINT PAUL ST STE 2
BOONSBORO MD
21713-1334
US

V. Phone/Fax

Practice location:
  • Phone: 301-381-4586
  • Fax:
Mailing address:
  • Phone: 301-381-4586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: DIANNE WENCZKOWSKI
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 301-381-4586