Healthcare Provider Details

I. General information

NPI: 1558285916
Provider Name (Legal Business Name): KINETIC BALANCE COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 FLUVIAL LN APT 406
LAUREL MD
20724-1396
US

IV. Provider business mailing address

3201 FLUVIAL LN APT 406
LAUREL MD
20724-1396
US

V. Phone/Fax

Practice location:
  • Phone: 443-455-1958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KASSANDRA IRENE BUTLER
Title or Position: PRESIDENT AND LCPC
Credential:
Phone: 407-492-3450