Healthcare Provider Details

I. General information

NPI: 1477267680
Provider Name (Legal Business Name): TRANSFORMATIONAL RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3202 GLENMORE AVE
BALTIMORE MD
21214-1815
US

IV. Provider business mailing address

3010 RIDGEWOOD AVE # 204
BALTIMORE MD
21215-6211
US

V. Phone/Fax

Practice location:
  • Phone: 443-398-1414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KENYA CONWAY
Title or Position: OWNER
Credential:
Phone: 443-398-1414