Basic Information
| Provider Information | |||||||||
| NPI: | 1467190900 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOMENTUM BEHAVIORAL HEALTH CONSULTANTS AND PARENT COACHING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6607 FANNON DR | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207204729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042848837 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6607 FANNON DR | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207204729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042848837 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | COLLEEN | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5042848837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.