=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003657040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRASSROOTS CRISIS INTERVENTION CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2024
-----------------------------------------------------
Last Update Date | 06/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8990 OLD ANNAPOLIS RD STE A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-2182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-531-6677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6700 FREETOWN RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21044-4137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-531-6006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. MARIANA IZRAELSON
-----------------------------------------------------
Credential | LCADC
-----------------------------------------------------
Telephone | 410-531-6006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------