Healthcare Provider Details

I. General information

NPI: 1609190750
Provider Name (Legal Business Name): TRANSFORMATION THERAPY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 HOSPITAL DR SUITE G-03
CLINTON MD
20735-3110
US

IV. Provider business mailing address

10401 HOSPITAL DR SUITE G-03
CLINTON MD
20735-3110
US

V. Phone/Fax

Practice location:
  • Phone: 301-856-6000
  • Fax: 301-856-8389
Mailing address:
  • Phone: 301-856-6000
  • Fax: 301-856-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number04071
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10425
License Number StateMD

VIII. Authorized Official

Name: MRS. KELLIE I JAMISON
Title or Position: LC SW-C
Credential: MSW
Phone: 301-856-6000