Healthcare Provider Details

I. General information

NPI: 1285135277
Provider Name (Legal Business Name): TAKOMA THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2018
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6930 CARROLL AVE STE 830
TAKOMA PARK MD
20912-4461
US

IV. Provider business mailing address

6930 CARROLL AVE STE 830
TAKOMA PARK MD
20912-4461
US

V. Phone/Fax

Practice location:
  • Phone: 301-802-5653
  • Fax:
Mailing address:
  • Phone: 301-802-5653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier416691400
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: SIMONE JACOBS
Title or Position: OWNER
Credential:
Phone: 301-802-5653