Healthcare Provider Details

I. General information

NPI: 1841647617
Provider Name (Legal Business Name): UNIVERSITY PSYCHOLOGICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W 25TH ST
BALTIMORE MD
21218-5003
US

IV. Provider business mailing address

21 W 25TH ST
BALTIMORE MD
21218-5003
US

V. Phone/Fax

Practice location:
  • Phone: 410-366-1717
  • Fax: 410-889-4176
Mailing address:
  • Phone: 410-366-1717
  • Fax: 410-889-4176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberMH-1881
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CLARK J HUDAK JR.
Title or Position: CEO
Credential: PH.D.
Phone: 410-576-9191