=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043544661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ATARAXIA GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2009
-----------------------------------------------------
Last Update Date | 09/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 W MAIN ST
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21157-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-833-6861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 W MAIN ST
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21157-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-833-6861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | KERILYN DERKASCH
-----------------------------------------------------
Credential | LGPC, NCC
-----------------------------------------------------
Telephone | 410-833-6861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LGP3244
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------