Healthcare Provider Details

I. General information

NPI: 1265011928
Provider Name (Legal Business Name): GRACELAND PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10451 MILL RUN CIR
OWINGS MILLS MD
21117-5577
US

IV. Provider business mailing address

9435 PARAGON CT
OWINGS MILLS MD
21117-1408
US

V. Phone/Fax

Practice location:
  • Phone: 888-517-4888
  • Fax:
Mailing address:
  • Phone: 240-722-9763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ADETIMBO ADEDIRAN
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: PMHNP
Phone: 240-722-9763