Healthcare Provider Details

I. General information

NPI: 1326525973
Provider Name (Legal Business Name): BEHAVIORAL HEALTH LEADERSHIP INSTITUTE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 EDGAR STREET (VAN)
BALTIMORE MD
21202
US

IV. Provider business mailing address

2200 ARDEN RD
BALTIMORE MD
21209-4205
US

V. Phone/Fax

Practice location:
  • Phone: 410-367-5878
  • Fax:
Mailing address:
  • Phone: 410-367-5878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH AGUS
Title or Position: EXECUTIVE DIRECTOR
Credential: JD
Phone: 410-367-5878