Healthcare Provider Details

I. General information

NPI: 1568058196
Provider Name (Legal Business Name): HERITAGE TREATMENT CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 04/04/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 EDMONDSON AVE STE 102
BALTIMORE MD
21229-1600
US

IV. Provider business mailing address

4200 EDMONDSON AVE STE 102
BALTIMORE MD
21229-1600
US

V. Phone/Fax

Practice location:
  • Phone: 443-224-0655
  • Fax:
Mailing address:
  • Phone: 443-224-0655
  • 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: TIFFANY LYNNELL BEANE
Title or Position: CO-OWNER
Credential:
Phone: 443-873-9389