Healthcare Provider Details

I. General information

NPI: 1164689576
Provider Name (Legal Business Name): ALTERNATIVE COUNSELING & WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 04/01/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E JOPPA RD STE 407
TOWSON MD
21286-3109
US

IV. Provider business mailing address

200 E JOPPA RD STE 407
TOWSON MD
21286-3109
US

V. Phone/Fax

Practice location:
  • Phone: 410-828-0101
  • Fax: 410-828-6262
Mailing address:
  • Phone: 410-828-0101
  • Fax: 410-828-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC1004
License Number StateMD

VII. Legacy identifiers

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

# 1
Identifier441156100
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: MS. VICTORIA S SHEQUINE
Title or Position: OWNER
Credential: LCPC
Phone: 410-433-3737