Healthcare Provider Details

I. General information

NPI: 1710357447
Provider Name (Legal Business Name): OPERATION WARRIOR REFUGE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25420 ROSEDALE MANOR LN
HOLLYWOOD MD
20636-2925
US

IV. Provider business mailing address

PO BOX 733
GREAT MILLS MD
20634-0733
US

V. Phone/Fax

Practice location:
  • Phone: 301-880-0531
  • Fax:
Mailing address:
  • Phone: 301-880-0531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC5662
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLC5662
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number05590
License Number StateMD

VIII. Authorized Official

Name: JULIA DEVINE
Title or Position: THERAPIST
Credential: LCPC
Phone: 240-298-6680