Healthcare Provider Details

I. General information

NPI: 1750042362
Provider Name (Legal Business Name): LUMINIS HEALTH BEHAVIORAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 GOOD LUCK RD
LANHAM MD
20706-3511
US

IV. Provider business mailing address

2000 MEDICAL PKWY STE 606
ANNAPOLIS MD
21401-3748
US

V. Phone/Fax

Practice location:
  • Phone: 301-623-4350
  • Fax: 301-623-4351
Mailing address:
  • Phone:
  • Fax:

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 Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER ODENWALD
Title or Position: COO
Credential:
Phone: 443-481-6415