Healthcare Provider Details

I. General information

NPI: 1619694239
Provider Name (Legal Business Name): PUDDS PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2413 REISTERSTOWN RD APT 1
BALTIMORE MD
21217-2056
US

IV. Provider business mailing address

3018 AUTUMN BRANCH LN APT E
ELLICOTT CITY MD
21043-3514
US

V. Phone/Fax

Practice location:
  • Phone: 443-633-3177
  • Fax:
Mailing address:
  • Phone: 443-633-3177
  • 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: SYKIA EDWARDS
Title or Position: CLINICAL DIRECTOR
Credential: CAC-AD-BAS, LMSW
Phone: 443-633-3177