MEDICARE: GAUDENZIA, 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	251V00000X	Voluntary or Charitable Agency
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1104261585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAUDENZIA, INC

Provider Business Mailing Address
First Line	:	3643 WOODLAND AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-5512
Country	:	US
Telephone Number	:	443-869-6298
Fax Number	:	443-849-6433

Provider Business Practice Location Address
First Line	:	4450 PARK HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-6324
Country	:	US
Telephone Number	:	443-869-6298
Fax Number	:	443-869-6433

Authorized Official
Title or Position	:	DIVISION DIRECTOR
Name	:	MRS. ANDREA PERSON
Credential	:	M.ED
Telephone Number	:	410-367-5501

Provider Enumeration Date	:	04/30/2013
Last Update Date	:	04/30/2013

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Directions to “GAUDENZIA, INC ” Practice Location

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