Healthcare Provider Details

I. General information

NPI: 1649694001
Provider Name (Legal Business Name): CHARLENE BRIDDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W PRATT ST
BALTIMORE MD
21223-2679
US

IV. Provider business mailing address

10400 RIDGLAND RD
COCKEYSVILLE MD
21030-2715
US

V. Phone/Fax

Practice location:
  • Phone: 443-462-3400
  • Fax: 443-462-3086
Mailing address:
  • Phone: 410-628-6120
  • Fax: 410-628-0953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP6232
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number101YA0400X
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: