Healthcare Provider Details

I. General information

NPI: 1275388043
Provider Name (Legal Business Name): VICTORY BEHAVIORAL SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8831 SATYR HILL RD STE 107
BALTIMORE MD
21234-2437
US

IV. Provider business mailing address

8831 SATYR HILL RD STE 107
BALTIMORE MD
21234-2437
US

V. Phone/Fax

Practice location:
  • Phone: 443-838-1700
  • Fax:
Mailing address:
  • Phone: 443-838-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARCELLA JACKSON
Title or Position: CEO
Credential: LMSW
Phone: 443-388-0211