Healthcare Provider Details

I. General information

NPI: 1780373324
Provider Name (Legal Business Name): NEW LIFE RECOVERY FOUNDATION CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 PARK AVE
BALTIMORE MD
21201-3618
US

IV. Provider business mailing address

302 PARK AVE
BALTIMORE MD
21201-3618
US

V. Phone/Fax

Practice location:
  • Phone: 410-304-6686
  • Fax: 443-836-9157
Mailing address:
  • Phone: 410-304-6686
  • Fax: 443-836-9157

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: VENNIETH MCCORMICK
Title or Position: CEO
Credential:
Phone: 410-908-3106