=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154320646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHPORT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2005
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 E MAIN ST
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-341-3420
-----------------------------------------------------
Fax | 410-341-3397
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 E MAIN ST STE C
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21801-4923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-341-3420
-----------------------------------------------------
Fax | 410-341-3397
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | KRISTINE GARTLITZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-202-2651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------