Healthcare Provider Details

I. General information

NPI: 1477199875
Provider Name (Legal Business Name): FREE BALTIMORE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N CHARLES ST # 303
BALTIMORE MD
21201-5592
US

IV. Provider business mailing address

PO BOX 26662
BALTIMORE MD
21207-0462
US

V. Phone/Fax

Practice location:
  • Phone: 443-416-5667
  • Fax:
Mailing address:
  • Phone: 443-416-5667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NORTHWEST REGISTERED AGENT SERVICES
Title or Position: REGISTERED AGENT
Credential:
Phone: 443-416-5667