Healthcare Provider Details

I. General information

NPI: 1255926564
Provider Name (Legal Business Name): COMMUNITY SUPPORT CONNECTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 LORD BALTIMORE DR STE 101
WINDSOR MILL MD
21244-5804
US

IV. Provider business mailing address

3100 LORD BALTIMORE DR STE 101
WINDSOR MILL MD
21244-5804
US

V. Phone/Fax

Practice location:
  • Phone: 443-348-3981
  • Fax:
Mailing address:
  • Phone: 443-348-3981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. OLUWAFEMI SHODIPE
Title or Position: ADMINISTRATOR
Credential:
Phone: 443-348-3981