Healthcare Provider Details

I. General information

NPI: 1558333138
Provider Name (Legal Business Name): BROOK LANE HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13215 BROOK LANE
HAGERSTOWN MD
21742-1435
US

IV. Provider business mailing address

13121 BROOK LANE
HAGERSTOWN MD
21742-1435
US

V. Phone/Fax

Practice location:
  • Phone: 301-733-0330
  • Fax: 301-733-4038
Mailing address:
  • Phone: 301-733-0330
  • Fax: 301-733-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number3016
License Number StateMD

VIII. Authorized Official

Name: DEBORAH L. BISENIEKS
Title or Position: PHYSICIAN MANAGER
Credential:
Phone: 301-733-0331