Healthcare Provider Details

I. General information

NPI: 1699357699
Provider Name (Legal Business Name): HOLISTIC TRACK INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PAINTERS MILL RD STE 108B
OWINGS MILLS MD
21117-4920
US

IV. Provider business mailing address

2504 SOMERTON CT
BOWIE MD
20721-2979
US

V. Phone/Fax

Practice location:
  • Phone: 240-552-0264
  • Fax: 443-441-5081
Mailing address:
  • Phone: 240-552-0264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EVARIST O OGUGUO
Title or Position: PRESIDENT
Credential: PMHNP, DNP
Phone: 240-552-0264