Healthcare Provider Details

I. General information

NPI: 1740871870
Provider Name (Legal Business Name): ONE PROMISE BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4314 HAMILTON AVE
BALTIMORE MD
21206-3641
US

IV. Provider business mailing address

6211 BELAIR RD
BALTIMORE MD
21206-1942
US

V. Phone/Fax

Practice location:
  • Phone: 443-835-2681
  • Fax:
Mailing address:
  • Phone: 443-835-2681
  • 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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CRAIG LIPPENS
Title or Position: PROGRAM ADMINISTRATOR
Credential:
Phone: 443-835-2681