Healthcare Provider Details

I. General information

NPI: 1730892035
Provider Name (Legal Business Name): INNOVATIVE TREATMENT CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 HOSPITAL DR STE 106
GLEN BURNIE MD
21061-5806
US

IV. Provider business mailing address

325 HOSPITAL DR STE 106
GLEN BURNIE MD
21061-5806
US

V. Phone/Fax

Practice location:
  • Phone: 917-873-5716
  • Fax:
Mailing address:
  • Phone: 917-873-5716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: TRAVIS A BAIRD
Title or Position: OWNER
Credential: NP
Phone: 443-430-2998