MEDICARE: UNIVERSITY PSYCHOLOGICAL CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	906200	MD

General Provider Information

NPI Number	:	1023545795
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY PSYCHOLOGICAL CENTER, INC

Provider Business Mailing Address
First Line	:	2617-19 N. CALVERT STREET
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218
Country	:	US
Telephone Number	:	410-576-9191
Fax Number	:	410-576-9257

Provider Business Practice Location Address
First Line	:	2617-19 N. CALVERT STREET
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218
Country	:	US
Telephone Number	:	410-576-9191
Fax Number	:	410-576-9257

Authorized Official
Title or Position	:	CEO
Name	:	DR. CLARK J HUDAK JR.
Credential	:	PH.D.
Telephone Number	:	410-576-9191

Provider Enumeration Date	:	05/12/2017
Last Update Date	:	05/12/2017

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