1104493337 NPI number — PRODUCTIVE LIVES MENTAL HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104493337 NPI number — PRODUCTIVE LIVES MENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRODUCTIVE LIVES MENTAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104493337
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 PAINTERS MILL RD STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWINGS MILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21117-5248
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-657-7952
Provider Business Mailing Address Fax Number:
443-657-7139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 PAINTERS MILL RD STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWINGS MILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21117-5248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-657-7952
Provider Business Practice Location Address Fax Number:
443-657-7139
Provider Enumeration Date:
06/07/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER-JOHNSON
Authorized Official First Name:
TOWANNA
Authorized Official Middle Name:
MONIQUE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
443-415-1937

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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