Healthcare Provider Details

I. General information

NPI: 1437822665
Provider Name (Legal Business Name): STREET ANGEL PROJECT PEER RECOVERY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 W WASHINGTON ST
ANNAPOLIS MD
21401-2432
US

IV. Provider business mailing address

55 CLAY ST
ANNAPOLIS MD
21401-2402
US

V. Phone/Fax

Practice location:
  • Phone: 443-949-9545
  • Fax:
Mailing address:
  • Phone: 443-591-2434
  • Fax: 240-336-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHIRLEY L GORDON
Title or Position: OWNER
Credential: CSAC,CMHT, CPRS,
Phone: 443-949-9545