Healthcare Provider Details

I. General information

NPI: 1104274547
Provider Name (Legal Business Name): CPE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 W 40TH ST 428
BALTIMORE MD
21211-2120
US

IV. Provider business mailing address

711 W 40TH ST 428
BALTIMORE MD
21211-2120
US

V. Phone/Fax

Practice location:
  • Phone: 410-979-2326
  • Fax: 877-979-2327
Mailing address:
  • Phone: 410-979-2326
  • Fax: 877-979-2327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL JOHN LABELLARTE SR.
Title or Position: PRINCIPLE
Credential: M.D.
Phone: 410-979-2326