Healthcare Provider Details

I. General information

NPI: 1962208454
Provider Name (Legal Business Name): AFFECT PROVIDER GROUP, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12410 MILESTONE CENTER DR OFC 670
GERMANTOWN MD
20876-7101
US

IV. Provider business mailing address

PO BOX 96635
PHOENIX AZ
85072-6635
US

V. Phone/Fax

Practice location:
  • Phone: 845-769-8758
  • Fax:
Mailing address:
  • Phone: 845-769-8758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KARLA RENEE MULLINGS
Title or Position: SECRETARY
Credential:
Phone: 845-768-8758