Healthcare Provider Details

I. General information

NPI: 1265914782
Provider Name (Legal Business Name): PERSONALIZED THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2018
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22593 THREE NOTCH RD
CALIFORNIA MD
20619-3054
US

IV. Provider business mailing address

22593 THREE NOTCH RD
CALIFORNIA MD
20619-3054
US

V. Phone/Fax

Practice location:
  • Phone: 301-862-2505
  • Fax: 301-862-2548
Mailing address:
  • Phone: 301-862-2505
  • Fax: 301-862-2548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: KRISTI GETSON
Title or Position: CHIEF OPERATING OFFICE
Credential:
Phone: 301-862-2505