Healthcare Provider Details

I. General information

NPI: 1043970510
Provider Name (Legal Business Name): EATHELL BERNICE LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 03/07/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9331 LIBERTY RD SUITE 2C
RANDALLSTOWN MD
21133-3525
US

IV. Provider business mailing address

3812 SANDY HOOK ROAD 3812 SAND
RANDALLSTOWN MD
21133
US

V. Phone/Fax

Practice location:
  • Phone: 443-414-9699
  • Fax:
Mailing address:
  • Phone: 443-414-9699
  • Fax: 443-279-6802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number211011733
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number21011733
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: