Healthcare Provider Details

I. General information

NPI: 1730066028
Provider Name (Legal Business Name): SACRED REBIRTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 SECURITY BLVD STE 100
BALTIMORE MD
21207-5284
US

IV. Provider business mailing address

6340 SECURITY BLVD STE 100
BALTIMORE MD
21207-5284
US

V. Phone/Fax

Practice location:
  • Phone: 443-653-6819
  • Fax:
Mailing address:
  • Phone: 443-653-6819
  • 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 Code171W00000X
TaxonomyContractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ALISE BURROW
Title or Position: CEO
Credential:
Phone: 443-653-6819