Healthcare Provider Details

I. General information

NPI: 1922880137
Provider Name (Legal Business Name): MIELJADE BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 SECURITY BLVD STE 100
BALTIMORE MD
21207-5284
US

IV. Provider business mailing address

26 UTICA DR
WORCESTER MA
01603-1623
US

V. Phone/Fax

Practice location:
  • Phone: 774-420-8760
  • Fax: 133-921-0899
Mailing address:
  • Phone: 774-420-8760
  • Fax: 339-210-8992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: DR. GIFTY AMPAW
Title or Position: CEO
Credential: PSYD, BCBA,LABA,LBA
Phone: 774-420-8760