Healthcare Provider Details

I. General information

NPI: 1508197120
Provider Name (Legal Business Name): CORNERSTONE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 EASTERN AVE JHBMC- MFL BUILDING, SUITE 353E
BALTIMORE MD
21224-2735
US

IV. Provider business mailing address

PO BOX 64260
BALTIMORE MD
21264-4260
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-7680
  • Fax:
Mailing address:
  • Phone: 410-933-2063
  • 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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: WAN-FANG TAYLOR
Title or Position: DIRECTOR A/R OPERATIONS
Credential:
Phone: 410-933-2063