Healthcare Provider Details

I. General information

NPI: 1154919223
Provider Name (Legal Business Name): ANGEL LEWIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4652 RIVERSTONE DR
OWINGS MILLS MD
21117-7029
US

IV. Provider business mailing address

PO BOX 940
RANDALLSTOWN MD
21133-0940
US

V. Phone/Fax

Practice location:
  • Phone: 240-432-3736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANGEL LEWIS
Title or Position: OWNER
Credential:
Phone: 240-432-3736