Healthcare Provider Details

I. General information

NPI: 1205460284
Provider Name (Legal Business Name): ISSIAIH HOUSE 1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406B CRAIN HWY S STE 201
GLEN BURNIE MD
21061-4336
US

IV. Provider business mailing address

4313 BRIGGS CHANEY RD
BELTSVILLE MD
20705-1044
US

V. Phone/Fax

Practice location:
  • Phone: 443-882-1943
  • Fax:
Mailing address:
  • Phone: 443-882-1943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. DARRYL BRAXTON
Title or Position: OWNER
Credential: LCAP, LCADC
Phone: 443-882-1943