Provider Demographics
NPI:1366215451
Name:WIRED DIFFERENTLY THERAPY LLC
Entity type:Organization
Organization Name:WIRED DIFFERENTLY THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:443-212-8137
Mailing Address - Street 1:1301 YORK ROAD, STE 800
Mailing Address - Street 2:#1028
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093
Mailing Address - Country:US
Mailing Address - Phone:443-212-8137
Mailing Address - Fax:
Practice Address - Street 1:9256 HOWARD SQUARE DR
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-6348
Practice Address - Country:US
Practice Address - Phone:443-212-8137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty