=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982023586
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEVATION & ENRICHMENT THERAPEUTIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2014
-----------------------------------------------------
Last Update Date | 09/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 PENN BELT PL
-----------------------------------------------------
City | DISTRICT HEIGHTS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20747-4734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-276-5312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3900 PENN BELT PL
-----------------------------------------------------
City | DISTRICT HEIGHTS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20747-4734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-276-5312
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. DARRELL LEWIS COLEMAN
-----------------------------------------------------
Credential | LCSW-C
-----------------------------------------------------
Telephone | 301-276-5312
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 19378
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------