Healthcare Provider Details

I. General information

NPI: 1114738978
Provider Name (Legal Business Name): VANTAGE BEHAVIORAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 01/20/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5457 TWIN KNOLLS RD STE 300-1116
COLUMBIA MD
21045-3259
US

IV. Provider business mailing address

5457 TWIN KNOLLS RD STE 300-1116
COLUMBIA MD
21045-3259
US

V. Phone/Fax

Practice location:
  • Phone: 667-417-9408
  • Fax: 667-417-9408
Mailing address:
  • Phone: 667-417-9408
  • Fax: 667-417-9408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ABIMBOLA C ADEBAYO
Title or Position: PRESIDENT
Credential:
Phone: 667-417-9408