Healthcare Provider Details

I. General information

NPI: 1124891759
Provider Name (Legal Business Name): URBAN TRAUMA COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 N MONTFORD AVE
BALTIMORE MD
21205-1620
US

IV. Provider business mailing address

3709 ESSEX RD
PIKESVILLE MD
21207-4617
US

V. Phone/Fax

Practice location:
  • Phone: 410-844-0770
  • Fax:
Mailing address:
  • Phone: 410-960-2496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SHINELLE OGLESBY
Title or Position: CEO
Credential:
Phone: 410-844-0770