MEDICARE: BLACK LIGHT THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1710832704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK LIGHT THERAPY, LLC

Provider Business Mailing Address
First Line	:	1307 SAINT PAUL STREET
Second Line	:	SECOND FLOOR, SUITE E
City	:	BALTIMORE
State	:	MD
Zip	:	21202-2712
Country	:	US
Telephone Number	:	425-876-2681
Fax Number	:

Provider Business Practice Location Address
First Line	:	1307 SAINT PAUL STREET
Second Line	:	SECOND FLOOR, SUITE E
City	:	BALTIMORE
State	:	MD
Zip	:	21202-2712
Country	:	US
Telephone Number	:	425-876-2681
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	RHONDA ELAINE MOORE
Credential	:
Telephone Number	:	425-876-2681

Provider Enumeration Date	:	03/04/2026
Last Update Date	:	06/11/2026

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