Healthcare Provider Details

I. General information

NPI: 1487280087
Provider Name (Legal Business Name): GEMINI HEALTH HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 BACK ACRE CIR
MOUNT AIRY MD
21771-7768
US

IV. Provider business mailing address

2702 BACK ACRE CIR STE 290B2702
MOUNT AIRY MD
21771-7769
US

V. Phone/Fax

Practice location:
  • Phone: 301-703-8767
  • Fax: 301-703-8886
Mailing address:
  • Phone: 301-703-8767
  • Fax: 301-703-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: STACI POWELL
Title or Position: MANAGER
Credential: DO
Phone: 301-706-8767