Healthcare Provider Details

I. General information

NPI: 1205505971
Provider Name (Legal Business Name): RADICAL RESTORATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 TAYLOR AVE STE 302
TOWSON MD
21286-8334
US

IV. Provider business mailing address

1055 TAYLOR AVE STE 302
TOWSON MD
21286-8334
US

V. Phone/Fax

Practice location:
  • Phone: 410-622-4818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LATANYA NICOLE TOWNSEND
Title or Position: CEO
Credential: PH.D, LCSW-C
Phone: 410-622-4818