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General NPI Number Information
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NPI Number | 1245762004
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Entity Type | Organization
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Legal Business Name | THERAPY 4 THE SPIRIT, LLC
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Dates
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Enumeration Date | 03/31/2017
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Last Update Date | 03/31/2017
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Provider Practice Location Address
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Address Line | 5401 TWIN KNOLLS RD STE 9
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City | COLUMBIA
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State | MD
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Zip | 21045-3257
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Country | US
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Telephone | 410-884-2848
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Fax | 410-884-2849
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Provider Business Mailing Address
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Address Line | 5401 TWIN KNOLLS RD STE 9
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City | COLUMBIA
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State | MD
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Zip | 21045-3257
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Country | US
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Telephone | 410-884-2848
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Fax | 410-884-2849
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Authorized Official
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Title or Position | OWNER, PSYCHOTHERAPIST
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Name | JACQUELINE MARIE SEGUE-WILKINS
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Credential | LCPC
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Telephone | 410-884-2848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LC3362
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License Number State | MD
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