Healthcare Provider Details

I. General information

NPI: 1134501836
Provider Name (Legal Business Name): RESTORATION COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 W ROLLING SUITE 210
CATONSVILLE MD
21228-6208
US

IV. Provider business mailing address

4709 CREEKSIDE CIR APARTMENT 302
OWINGS MILLS MD
21117-7125
US

V. Phone/Fax

Practice location:
  • Phone: 410-744-7014
  • Fax: 410-744-6903
Mailing address:
  • Phone: 919-332-4043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number15128
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number15128
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number15128
License Number StateMD

VIII. Authorized Official

Name: KRYSTAL LASHON SMITH
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW-C
Phone: 919-332-4043