Provider Demographics
NPI:1386460038
Name:MARYLAND FAMILY THERAPY, LLC
Entity type:Organization
Organization Name:MARYLAND FAMILY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRINCESS
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUVENIR
Authorized Official - Suffix:
Authorized Official - Credentials:DBH, LCPC
Authorized Official - Phone:313-815-5967
Mailing Address - Street 1:100 HARBORVIEW DR UNIT 2109
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HARBORVIEW DR UNIT 2109
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-5449
Practice Address - Country:US
Practice Address - Phone:617-659-5299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty