=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104051440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUMINIS HEALTH MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2009
-----------------------------------------------------
Last Update Date | 10/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8200 GOOD LUCK RD
-----------------------------------------------------
City | LANHAM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20706-3511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-623-4350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 DEFENSE HWY STE 150
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-8953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-481-6476
-----------------------------------------------------
Fax | 443-481-6515
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AO
-----------------------------------------------------
Name | MELISSA RAPATTONI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-481-5136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WP0807X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------