Healthcare Provider Details

I. General information

NPI: 1245808666
Provider Name (Legal Business Name): ICON CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2021
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7735 BELLE POINT DR
GREENBELT MD
20770-3300
US

IV. Provider business mailing address

7735 BELLE POINT DR
GREENBELT MD
20770-3300
US

V. Phone/Fax

Practice location:
  • Phone: 240-455-3166
  • Fax: 240-455-4154
Mailing address:
  • Phone: 240-455-3166
  • Fax: 240-455-4154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. THICKNESS PATRICK EGWUATU
Title or Position: PROVIDER/CEO
Credential: BC-PMHNP
Phone: 202-288-7752