Provider Demographics
NPI:1053033126
Name:ETW THERAPEUTIC & HOLISTIC SERVICES LLC
Entity type:Organization
Organization Name:ETW THERAPEUTIC & HOLISTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PRIYANKA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALHOTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-377-1836
Mailing Address - Street 1:7206 SHOCKLEY CT
Mailing Address - Street 2:
Mailing Address - City:FT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-1711
Mailing Address - Country:US
Mailing Address - Phone:202-743-5660
Mailing Address - Fax:410-824-1482
Practice Address - Street 1:7305 BALTIMORE AVE # A101
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-3234
Practice Address - Country:US
Practice Address - Phone:202-743-5660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-15
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD555991000Medicaid