Healthcare Provider Details

I. General information

NPI: 1154993350
Provider Name (Legal Business Name): ADVANCED BEHAVIORAL HEALTH SOLUTIONS - LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 CRAIN HWY N STE 2B
GLEN BURNIE MD
21061-9304
US

IV. Provider business mailing address

3523 CORN STREAM RD
RANDALLSTOWN MD
21133-2442
US

V. Phone/Fax

Practice location:
  • Phone: 443-870-1037
  • Fax:
Mailing address:
  • Phone: 410-528-3866
  • Fax:

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: SUNNY B DIFFANG
Title or Position: OWNER OF ENTITY
Credential: MSN, PMHNP-BC
Phone: 410-528-3866