Healthcare Provider Details

I. General information

NPI: 1649865437
Provider Name (Legal Business Name): INTENTIONAL HEALING THERAPEUTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ALLEGHENY AVE STE 101
TOWSON MD
21204-4219
US

IV. Provider business mailing address

6012 LOCH RAVEN BLVD
BALTIMORE MD
21239-2307
US

V. Phone/Fax

Practice location:
  • Phone: 443-720-0806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. SARITA HINTON
Title or Position: PROVIDER
Credential:
Phone: 443-720-0806