Healthcare Provider Details

I. General information

NPI: 1053226902
Provider Name (Legal Business Name): EXPRESS YOURSELF BLACK MAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 THAYER CENTER STE C
OAKLAND MD
21550
US

IV. Provider business mailing address

3 GERMAY DR, STE 4 UNIT #1798
WILMINGTON DE
19804
US

V. Phone/Fax

Practice location:
  • Phone: 862-955-1109
  • Fax:
Mailing address:
  • Phone: 862-955-1109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: KOFI FORSON
Title or Position: FOUNDER
Credential:
Phone: 862-955-1109