Healthcare Provider Details

I. General information

NPI: 1417879420
Provider Name (Legal Business Name): COMMUNITY BASED SEVICES PRP AT EQUANIMITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10665 STANHAVEN PL
WHITE PLAINS MD
20695-3055
US

IV. Provider business mailing address

10665 STANHAVEN PL
WHITE PLAINS MD
20695-3055
US

V. Phone/Fax

Practice location:
  • Phone: 404-980-4808
  • Fax: 240-241-6360
Mailing address:
  • Phone: 404-980-4808
  • Fax: 240-241-6360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. TAVIN PARKER
Title or Position: MEMBER
Credential:
Phone: 404-980-4808