Healthcare Provider Details

I. General information

NPI: 1386370757
Provider Name (Legal Business Name): TRANSFORMATION STATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 EDMONDSON AVE STE 100
BALTIMORE MD
21229-1617
US

IV. Provider business mailing address

4200 EDMONDSON AVE STE 100
BALTIMORE MD
21229-1617
US

V. Phone/Fax

Practice location:
  • Phone: 443-873-8139
  • Fax:
Mailing address:
  • Phone: 443-873-8139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. DARRYL MOODY
Title or Position: OWNER
Credential:
Phone: 443-310-2572