Healthcare Provider Details

I. General information

NPI: 1811689599
Provider Name (Legal Business Name): HOLISTIC TELEPSYCH & MED MGT. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/22/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8306 LARCHWOOD ST
NEW CARROLLTON MD
20784-3409
US

IV. Provider business mailing address

8306 LARCHWOOD ST
NEW CARROLLTON MD
20784-3409
US

V. Phone/Fax

Practice location:
  • Phone: 301-741-2232
  • Fax:
Mailing address:
  • Phone: 301-741-2232
  • Fax: 301-459-4252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LEWIS CHRISTOPHER WILSON
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: PSYCH NP
Phone: 301-741-2232