Healthcare Provider Details

I. General information

NPI: 1245762004
Provider Name (Legal Business Name): THERAPY 4 THE SPIRIT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 TWIN KNOLLS RD STE 9
COLUMBIA MD
21045-3257
US

IV. Provider business mailing address

5401 TWIN KNOLLS RD STE 9
COLUMBIA MD
21045-3257
US

V. Phone/Fax

Practice location:
  • Phone: 410-884-2848
  • Fax: 410-884-2849
Mailing address:
  • Phone: 410-884-2848
  • Fax: 410-884-2849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLC3362
License Number StateMD

VIII. Authorized Official

Name: JACQUELINE MARIE SEGUE-WILKINS
Title or Position: OWNER, PSYCHOTHERAPIST
Credential: LCPC
Phone: 410-884-2848