Healthcare Provider Details

I. General information

NPI: 1477237303
Provider Name (Legal Business Name): ABOUT A HEALTHY BRAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19403 BUCKINGHAM WAY
GERMANTOWN MD
20874-4665
US

IV. Provider business mailing address

12774 WISTERIA DR 2724
GERMANTOWN MD
20875
US

V. Phone/Fax

Practice location:
  • Phone: 240-756-1682
  • Fax:
Mailing address:
  • Phone: 240-756-1682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEBRA APRIL LATOAK LEE
Title or Position: NURSE PRACTITIONER
Credential: PMHNP B.C.
Phone: 240-756-1682