=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962204644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFECT PROVIDER GROUP, P.S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2025
-----------------------------------------------------
Last Update Date | 05/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12410 MILESTONE CENTER DR OFC 670
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20876-7101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-691-9101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1640 BORO PL FL 4
-----------------------------------------------------
City | MC LEAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22102-3627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-691-9101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIR. OF COMPLIANCE
-----------------------------------------------------
Name | KARLA RENEE MULLINGS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 845-768-8758
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------