Healthcare Provider Details

I. General information

NPI: 1053073940
Provider Name (Legal Business Name): ESHCOL BEHAVIORAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6223 SWEET GUM LN
HANOVER MD
21076-2127
US

IV. Provider business mailing address

6223 SWEET GUM LN
HANOVER MD
21076-2127
US

V. Phone/Fax

Practice location:
  • Phone: 617-461-3856
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: AKHERE GWAN
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: NP
Phone: 617-461-3856