Healthcare Provider Details

I. General information

NPI: 1104326487
Provider Name (Legal Business Name): EPIPHANY FAMILY SERVICES- MARYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 BELAIR RD 2ND FLOOR SUITE 2
BALTIMORE MD
21213-1257
US

IV. Provider business mailing address

3301 BELAIR RD 2ND FLOOR SUITE 2
BALTIMORE MD
21213-1257
US

V. Phone/Fax

Practice location:
  • Phone: 443-873-7193
  • Fax: 410-630-7882
Mailing address:
  • Phone: 443-873-7193
  • Fax: 410-630-7882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateMD
# 7
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTHONY ESTREET
Title or Position: CEO/EXECUTIVE DIRECTOR
Credential: LCSW-C, LCADC
Phone: 443-873-7193