Healthcare Provider Details

I. General information

NPI: 1881100857
Provider Name (Legal Business Name): CITYWIDE BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 WARREN RD STE 20B
BALTIMORE MD
21208-5334
US

IV. Provider business mailing address

17 WARREN RD STE 20B
BALTIMORE MD
21208-5334
US

V. Phone/Fax

Practice location:
  • Phone: 410-929-2314
  • Fax: 410-484-8107
Mailing address:
  • Phone: 410-929-2314
  • Fax: 410-484-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PAMELA JOHNSON
Title or Position: OWNER
Credential: CRNP
Phone: 410-274-8688