Healthcare Provider Details

I. General information

NPI: 1063399012
Provider Name (Legal Business Name): EDEN PLACE HEALING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 FAIRVIEW AVE
BALTIMORE MD
21216-1229
US

IV. Provider business mailing address

PO BOX 2602
BALTIMORE MD
21215-0003
US

V. Phone/Fax

Practice location:
  • Phone: 443-674-6343
  • Fax:
Mailing address:
  • Phone: 443-674-6343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LOVELY MOULTON
Title or Position: EXECUTIVE DIRECTOR
Credential: LCPC, LCADC
Phone: 443-674-6343