Healthcare Provider Details

I. General information

NPI: 1437880770
Provider Name (Legal Business Name): FOUNTAIN HEALTH SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W 24TH ST STE D
BALTIMORE MD
21211-3216
US

IV. Provider business mailing address

1305 SUDVALE RD
PIKESVILLE MD
21208-4114
US

V. Phone/Fax

Practice location:
  • Phone: 443-525-2019
  • Fax: 410-630-3600
Mailing address:
  • Phone: 443-525-2019
  • Fax: 410-630-3600

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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: OLANIKE K OSUNNUYI
Title or Position: CEO
Credential:
Phone: 443-525-2019