=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245778034
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE GRATITUDE CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2017
-----------------------------------------------------
Last Update Date | 02/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7979 OLD GEORGETOWN RD SUITE 310
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-804-7231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7979 OLD GEORGETOWN RD SUITE 310
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814-2429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-804-7231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL WENISCH
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 301-804-7231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LC7438
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------