Healthcare Provider Details

I. General information

NPI: 1043737893
Provider Name (Legal Business Name): CLOVER BEHAVIOR CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 KING FARM BLVD
ROCKVILLE MD
20850
US

IV. Provider business mailing address

402 KING FARM BLVD
ROCKVILLE MD
20850-5843
US

V. Phone/Fax

Practice location:
  • Phone: 240-304-6604
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1118537
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: COLLEEN WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 240-304-6604