Healthcare Provider Details

I. General information

NPI: 1225779234
Provider Name (Legal Business Name): ENTRO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4439 BELAIR RD
BALTIMORE MD
21206-6337
US

IV. Provider business mailing address

4439 BELAIR RD
BALTIMORE MD
21206-6337
US

V. Phone/Fax

Practice location:
  • Phone: 410-262-6030
  • Fax:
Mailing address:
  • Phone: 410-262-6030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. TONYIA GODLOCK
Title or Position: OWNER
Credential: LMSW
Phone: 410-262-6030