Healthcare Provider Details

I. General information

NPI: 1902375090
Provider Name (Legal Business Name): PORT RECOVERY MENTAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8615 RIDGELYS CHOICE DR STE 205
NOTTINGHAM MD
21236-3028
US

IV. Provider business mailing address

8615 RIDGELYS CHOICE DR STE 205
NOTTINGHAM MD
21236-3028
US

V. Phone/Fax

Practice location:
  • Phone: 443-869-4909
  • Fax: 443-869-4928
Mailing address:
  • Phone: 410-534-8735
  • Fax: 410-534-8737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOANNE GRANRUTH
Title or Position: OWNER
Credential:
Phone: 410-534-8735