Healthcare Provider Details

I. General information

NPI: 1083479919
Provider Name (Legal Business Name): NSNS REENTRY PALLIATIVE OUTPATIENT CARE, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 MARYLAND AVE
BALTIMORE MD
21218-5918
US

IV. Provider business mailing address

2025 MARYLAND AVE
BALTIMORE MD
21218-5918
US

V. Phone/Fax

Practice location:
  • Phone: 443-202-3127
  • Fax:
Mailing address:
  • Phone: 443-202-3127
  • Fax:

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JANETTE GONZALEZ-GRAHAM
Title or Position: DIRECTOR
Credential: BS, GPC
Phone: 443-202-3127