Healthcare Provider Details

I. General information

NPI: 1760408165
Provider Name (Legal Business Name): GRANITE HOUSE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 E GREEN ST
WESTMINSTER MD
21157-5410
US

IV. Provider business mailing address

288 E GREEN ST
WESTMINSTER MD
21157-5410
US

V. Phone/Fax

Practice location:
  • Phone: 410-876-3007
  • Fax: 410-751-7797
Mailing address:
  • Phone: 410-876-3007
  • Fax: 410-751-7797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateMD

VIII. Authorized Official

Name: MR. SPENCER L GEAR
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW-C
Phone: 410-876-3007