Healthcare Provider Details

I. General information

NPI: 1184590697
Provider Name (Legal Business Name): BO HUNDLEY ASSEFA SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3212 FAIT AVE
BALTIMORE MD
21224-4031
US

IV. Provider business mailing address

3212 FAIT AVE
BALTIMORE MD
21224-4031
US

V. Phone/Fax

Practice location:
  • Phone: 410-206-7460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: BO HUNDLEY ASSEFA
Title or Position: OWNER
Credential: LCPAT
Phone: 410-206-7460