Healthcare Provider Details

I. General information

NPI: 1881303014
Provider Name (Legal Business Name): VIN PALE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8219 CHESTNUT AVE
BOWIE MD
20715-4523
US

IV. Provider business mailing address

8219 CHESTNUT AVE
BOWIE MD
20715-4523
US

V. Phone/Fax

Practice location:
  • Phone: 718-288-7626
  • Fax:
Mailing address:
  • Phone: 718-288-7626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLORAINE BENOIT
Title or Position: DIRECTOR
Credential: LCSW-C, LICSW
Phone: 718-288-7626