Healthcare Provider Details

I. General information

NPI: 1386094803
Provider Name (Legal Business Name): CHRYSALIS HOUSE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 FREDERICK AVE
BALTIMORE MD
21229-4101
US

IV. Provider business mailing address

1570 CROWNSVILLE RD
CROWNSVILLE MD
21032-2306
US

V. Phone/Fax

Practice location:
  • Phone: 410-974-6829
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER MCCABE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 410-974-6829