Healthcare Provider Details

I. General information

NPI: 1932658671
Provider Name (Legal Business Name): IMARA COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 10/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 SANDY SPRING RD 250
LAUREL MD
20707-3596
US

IV. Provider business mailing address

8101 SANDY SPRING RD 250
LAUREL MD
20707-3596
US

V. Phone/Fax

Practice location:
  • Phone: 301-821-0049
  • Fax:
Mailing address:
  • Phone: 301-821-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC6147
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC6147
License Number StateMD

VIII. Authorized Official

Name: DAVID DEFOE
Title or Position: OWNER
Credential:
Phone: 301-821-0049