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General NPI Number Information
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NPI Number | 1518642792
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Entity Type | Organization
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Legal Business Name | MY VILLAGE THERAPEUTIC SERVICES, LLC
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Dates
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Enumeration Date | 06/16/2023
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Last Update Date | 01/16/2025
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Provider Practice Location Address
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Address Line | 802 N FULTON AVE
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City | BALTIMORE
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State | MD
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Zip | 21217-1425
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Country | US
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Telephone | 443-885-0287
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Fax |
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Provider Business Mailing Address
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Address Line | 5457 TWIN KNOLLS ROAD SUITE 300, #1314
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City | COLUMBIA
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State | MD
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Zip | 21045
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Country | US
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Telephone | 443-885-0287
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Fax |
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Authorized Official
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Title or Position | FOUNDER/CEO/THERAPIST
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Name | SHANAE GARDNER
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Credential | LCSW-C
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Telephone | 443-885-0287
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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