Healthcare Provider Details

I. General information

NPI: 1174397939
Provider Name (Legal Business Name): PHAZE COUNSELING SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8007 CORPORATE DR STE A
NOTTINGHAM MD
21236-4905
US

IV. Provider business mailing address

8007 CORPORATE DR STE A
NOTTINGHAM MD
21236-4905
US

V. Phone/Fax

Practice location:
  • Phone: 410-874-9595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHANNTEL MONIQUE GLADNEY
Title or Position: CEO
Credential:
Phone: 443-622-8755