Healthcare Provider Details

I. General information

NPI: 1992372312
Provider Name (Legal Business Name): DAVIDS LOFT CENTER FOR SOMATIC AND BEHAVIORAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2641 MARYLAND AVE
BALTIMORE MD
21218-4518
US

IV. Provider business mailing address

2641 MARYLAND AVE
BALTIMORE MD
21218-4518
US

V. Phone/Fax

Practice location:
  • Phone: 410-800-4226
  • Fax:
Mailing address:
  • Phone: 410-800-4226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DAVID H THOMPSON JR.
Title or Position: CEO
Credential: LCPC
Phone: 410-800-4285