Healthcare Provider Details

I. General information

NPI: 1740984137
Provider Name (Legal Business Name): URBAN THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16701 MELFORD BLVD STE 400
BOWIE MD
20715-4411
US

IV. Provider business mailing address

9492 PEP RALLY LN
WALDORF MD
20603-3759
US

V. Phone/Fax

Practice location:
  • Phone: 240-741-5096
  • Fax:
Mailing address:
  • Phone: 301-339-4880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: AYISHA JONES KEITH
Title or Position: CLINICAL SOCIAL WORKER
Credential: LICSW
Phone: 240-741-5096