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General NPI Number Information
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NPI Number | 1609163450
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Entity Type | Organization
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Legal Business Name | THE BODY IMAGE THERAPY CENTER LLC
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Dates
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Enumeration Date | 06/30/2011
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Last Update Date | 06/30/2011
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Provider Practice Location Address
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Address Line | 8940 OLD ANNAPOLIS RD SUITE E
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City | COLUMBIA
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State | MD
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Zip | 21045-2129
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Country | US
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Telephone | 443-602-6515
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Fax | 443-546-1100
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Provider Business Mailing Address
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Address Line | 8940 OLD ANNAPOLIS RD SUITE E
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City | COLUMBIA
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State | MD
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Zip | 21045-2129
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Country | US
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Telephone | 443-602-6515
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Fax | 443-546-1100
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Authorized Official
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Title or Position | OWNER, EXECUTIVE DIRECTOR
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Name | ANDREW WALEN
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Credential | LCSW-C
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Telephone | 443-602-6515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LC3911
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 15245
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License Number State | MD
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