Healthcare Provider Details

I. General information

NPI: 1306472964
Provider Name (Legal Business Name): CREATED FOR GREATER HEALTH SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 N CAROLINE ST
BALTIMORE MD
21213-2804
US

IV. Provider business mailing address

5411 OLD FREDERICK RD STE 9
BALTIMORE MD
21229-2126
US

V. Phone/Fax

Practice location:
  • Phone: 443-315-5007
  • Fax:
Mailing address:
  • Phone: 443-315-5007
  • Fax: 443-251-5395

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 Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: LAKIA THOMPSON
Title or Position: CEO
Credential: LCSW-C
Phone: 443-315-5007