Provider Demographics
NPI:1730809732
Name:FRESH START THERAPEUTIC SERVICES, LLC
Entity type:Organization
Organization Name:FRESH START THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TEKORA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-370-9479
Mailing Address - Street 1:626 TOWNE CENTER DR STE 204
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-4451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:626 TOWNE CENTER DR STE 204
Practice Address - Street 2:
Practice Address - City:JOPPA
Practice Address - State:MD
Practice Address - Zip Code:21085-4451
Practice Address - Country:US
Practice Address - Phone:443-313-3241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)