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General NPI Number Information
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NPI Number | 1124223979
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Entity Type | Organization
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Legal Business Name | COLLINGTON SQUARE NON PROFIT CORPORATION
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Dates
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Enumeration Date | 06/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1211 N CHESTER ST
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City | BALTIMORE
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State | MD
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Zip | 21213-3330
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Country | US
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Telephone | 410-342-6858
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Fax |
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Provider Business Mailing Address
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Address Line | 1211 N CHESTER ST
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City | BALTIMORE
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State | MD
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Zip | 21213-3330
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Country | US
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Telephone | 410-342-6858
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. JEWEL GRAY
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Credential | ED.D
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Telephone | 410-342-6858
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number | 101466
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License Number State | MD
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