Healthcare Provider Details

I. General information

NPI: 1285816140
Provider Name (Legal Business Name): BALTIMORE BEHAVIORAL HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W PRATT STREET
BALTIMORE MD
21223
US

IV. Provider business mailing address

1101 W PRATT ST
BALTIMORE MD
21223
US

V. Phone/Fax

Practice location:
  • Phone: 410-962-7180
  • Fax: 410-962-7194
Mailing address:
  • Phone: 410-962-7180
  • Fax: 410-962-7194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateMD
# 7
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateMD

VIII. Authorized Official

Name: WILLIAM K HATHAWAY
Title or Position: CEO
Credential:
Phone: 410-962-7190