Healthcare Provider Details

I. General information

NPI: 1518613264
Provider Name (Legal Business Name): RESTORATIVE BEHAVIOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 APOLLO DR
UPPER MARLBORO MD
20774-4783
US

IV. Provider business mailing address

9701 APOLLO DR
UPPER MARLBORO MD
20774-4783
US

V. Phone/Fax

Practice location:
  • Phone: 301-798-6125
  • Fax: 301-355-0276
Mailing address:
  • Phone: 301-798-6125
  • Fax: 301-355-0276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. EBONIQUE KATRESS MCCLINNAHAN
Title or Position: OWNER AND CLINICIAN
Credential: RN, MSN, PMHNP-BC
Phone: 910-797-1491