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NPI Code Detail

MEDICARE: PORT RECOVERY MENTAL HEALTH, INC.

MEDICARE: PORT RECOVERY MENTAL HEALTH, 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
1101YP2500XProfessional Counselor
21041C0700XClinical Social Worker
3363LP0808XPsychiatric/Mental Health Nurse Practitioner
4101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1902375090
Entity Type Code : Organization
Provider Name (Legal Business Name) : PORT RECOVERY MENTAL HEALTH, INC.
Provider Business Mailing Address
First Line : 8615 RIDGELYS CHOICE DR STE 205
Second Line :
City : NOTTINGHAM
State : MD
Zip : 21236-3028
Country : US
Telephone Number : 410-534-8735
Fax Number : 410-534-8737
Provider Business Practice Location Address
First Line : 8615 RIDGELYS CHOICE DR STE 205
Second Line :
City : NOTTINGHAM
State : MD
Zip : 21236-3028
Country : US
Telephone Number : 443-869-4909
Fax Number : 443-869-4928
Authorized Official
Title or Position : OWNER
Name : JOANNE GRANRUTH
Credential :
Telephone Number : 410-534-8735
Provider Enumeration Date : 11/19/2018
Last Update Date : 11/19/2018

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