Healthcare Provider Details

I. General information

NPI: 1457839284
Provider Name (Legal Business Name): I'M STILL STANDING BY GRACE MENTAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 E PATAPSCO AVE
BALTIMORE MD
21225-2228
US

IV. Provider business mailing address

1003 E PATAPSCO AVE
BALTIMORE MD
21225-2228
US

V. Phone/Fax

Practice location:
  • Phone: 410-355-1379
  • Fax: 410-355-2350
Mailing address:
  • Phone: 443-831-0191
  • Fax: 410-355-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberBH001052
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberBH001052
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberBH001052
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberBH001052
License Number StateMD

VIII. Authorized Official

Name: MISS PAMELA DUKES
Title or Position: PROGRAM OWNER
Credential: MHS, CPC, CAC-AD
Phone: 443-831-0191