Healthcare Provider Details

I. General information

NPI: 1669952750
Provider Name (Legal Business Name): RECLAIMING OUR CHILDREN & COMMUNITY PROJECT.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E NORTHERN PKWY STE 204
BALTIMORE MD
21239-2110
US

IV. Provider business mailing address

314 JOPPA CROSSING WAY
JOPPA MD
21085-3742
US

V. Phone/Fax

Practice location:
  • Phone: 443-759-9706
  • Fax: 443-759-9707
Mailing address:
  • Phone: 443-226-6866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateMD

VIII. Authorized Official

Name: DANTE WILSON
Title or Position: CEO
Credential:
Phone: 443-759-9706