Healthcare Provider Details

I. General information

NPI: 1376701193
Provider Name (Legal Business Name): THE HOUSE OF JUDE CHILDREN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/03/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E. 25TH STREET
BALTIMORE MD
21218
US

IV. Provider business mailing address

P.O. BOX 5004
MIDDLE RIVER MD
21220
US

V. Phone/Fax

Practice location:
  • Phone: 410-705-1331
  • Fax: 410-938-2237
Mailing address:
  • Phone: 410-705-1331
  • Fax: 410-938-2237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberLC-2284
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberNCC-93405
License Number StateMD

VIII. Authorized Official

Name: EDITH AUGUSTSON
Title or Position: OWNER
Credential: NCC, LCPC, LCADC
Phone: 410-705-1331