Healthcare Provider Details

I. General information

NPI: 1295208932
Provider Name (Legal Business Name): DETERMINED DRIVEN AND DEDICATED FOR LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 OWINGS PARK DR APT L
OWINGS MILLS MD
21117-3586
US

IV. Provider business mailing address

9200 OWINGS PARK DR APT L
OWINGS MILLS MD
21117-3586
US

V. Phone/Fax

Practice location:
  • Phone: 410-302-4418
  • Fax:
Mailing address:
  • Phone: 410-302-4418
  • 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 Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. ZAKIA MCALLISTER
Title or Position: CEO
Credential:
Phone: 410-302-4418