Healthcare Provider Details

I. General information

NPI: 1104366640
Provider Name (Legal Business Name): ON THE FLIP SIDE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3739 WILKENS AVE
BALTIMORE MD
21229-5035
US

IV. Provider business mailing address

PO BOX 32633
BALTIMORE MD
21282-2633
US

V. Phone/Fax

Practice location:
  • Phone: 410-831-2138
  • Fax:
Mailing address:
  • Phone: 410-831-2138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number4221133
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number16681
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number16681
License Number StateMD

VIII. Authorized Official

Name: MISS KEAH CROSBY
Title or Position: CEO
Credential: LCSW-C, CCM
Phone: 410-831-2138