Healthcare Provider Details

I. General information

NPI: 1366656175
Provider Name (Legal Business Name): GAUDENZIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4615 PARK HEIGHTS AVE
BALTIMORE MD
21215-6331
US

IV. Provider business mailing address

106 W MAIN ST
NORRISTOWN PA
19401-4716
US

V. Phone/Fax

Practice location:
  • Phone: 443-423-1500
  • Fax: 443-423-1495
Mailing address:
  • Phone: 610-239-9600
  • Fax: 610-275-7025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number12536
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number10478
License Number StateMD

VIII. Authorized Official

Name: MIKE WILLIAMS
Title or Position: SR. CONTRACTING MANAGER
Credential:
Phone: 484-338-3731