=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083576755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUNCTIONALLY THRIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2025
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2345 YORK RD STE 304
-----------------------------------------------------
City | LUTHERVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-2283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-707-9350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2345 YORK RD STE 304
-----------------------------------------------------
City | LUTHERVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-2283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/CLINICAL DIRECTOR
-----------------------------------------------------
Name | DARIELLE DAVIS
-----------------------------------------------------
Credential | BCBA,LBA
-----------------------------------------------------
Telephone | 443-707-9350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------