Healthcare Provider Details

I. General information

NPI: 1679923056
Provider Name (Legal Business Name): WOODBOURNE SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 WOODBOURNE AVE
BALTIMORE MD
21239-3316
US

IV. Provider business mailing address

1301 WOODBOURNE AVE
BALTIMORE MD
21239-3316
US

V. Phone/Fax

Practice location:
  • Phone: 410-433-1000
  • Fax: 410-433-1459
Mailing address:
  • Phone: 410-433-1000
  • Fax: 410-433-1459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number3875
License Number StateMD

VIII. Authorized Official

Name: MR. ANTHONY WILSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 410-433-1000