Healthcare Provider Details

I. General information

NPI: 1659829398
Provider Name (Legal Business Name): WOODBOURNE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 WOODBOURNE AVE
BALTIMORE MD
21239-3316
US

IV. Provider business mailing address

1301 WOODBOURNE AVE
BALTIMORE MD
21239-3316
US

V. Phone/Fax

Practice location:
  • Phone: 410-433-1000
  • Fax: 410-433-1459
Mailing address:
  • Phone: 410-433-1000
  • Fax: 410-433-1459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number30-073
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY WILSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 410-433-1000