Healthcare Provider Details

I. General information

NPI: 1427440882
Provider Name (Legal Business Name): ARISE THERAPY AND LIFE COACHING CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9135 PISCATAWAY RD 410
CLINTON MD
20735-2549
US

IV. Provider business mailing address

12105 WESTLOCK PL
LAUREL MD
20708-2422
US

V. Phone/Fax

Practice location:
  • Phone: 240-455-3453
  • Fax:
Mailing address:
  • Phone: 240-988-2417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number20070
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number20070
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number20070
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20070
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number20070
License Number StateMD

VIII. Authorized Official

Name: MRS. KELLIE JAMISON
Title or Position: CLINICAL SOCIAL WORKER
Credential:
Phone: 240-413-7003