Healthcare Provider Details

I. General information

NPI: 1114674058
Provider Name (Legal Business Name): ALTA HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LAKEFOREST BLVD STE 250
GAITHERSBURG MD
20877-2633
US

IV. Provider business mailing address

21506 MANOR VIEW CIR
GERMANTOWN MD
20876-5924
US

V. Phone/Fax

Practice location:
  • Phone: 240-801-9818
  • Fax:
Mailing address:
  • Phone: 240-506-1728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HANNAH DIBONGE
Title or Position: CEO
Credential:
Phone: 240-506-1728