Healthcare Provider Details

I. General information

NPI: 1891278024
Provider Name (Legal Business Name): ISSAIAH HOUSE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 EASTERN AVE
BALTIMORE MD
21224-4221
US

IV. Provider business mailing address

919 CALWELL RD
BALTIMORE MD
21229-5006
US

V. Phone/Fax

Practice location:
  • Phone: 443-882-1943
  • Fax:
Mailing address:
  • Phone: 144-388-2194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. DARRYL EDWARD BRAXTON
Title or Position: OWNER
Credential: LCPC, LCADC
Phone: 443-882-1943