Healthcare Provider Details

I. General information

NPI: 1649737453
Provider Name (Legal Business Name): BRANTWOOD FS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 AUGUSTINE HERMAN HWY
ELKTON MD
21921-8251
US

IV. Provider business mailing address

1190 AUGUSTINE HERMAN HWY
ELKTON MD
21921-8251
US

V. Phone/Fax

Practice location:
  • Phone: 443-655-5116
  • Fax:
Mailing address:
  • Phone: 410-398-0651
  • 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 Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. MARY GAMBLE
Title or Position: DIRECTOR
Credential: LCSW-C
Phone: 410-398-0651