=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235749771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TARGET BEHAVIORAL HEALTH SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2020
-----------------------------------------------------
Last Update Date | 07/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 E CHURCHVILLE RD STE 106
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21014-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-888-7143
-----------------------------------------------------
Fax | 410-888-7145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1415 MOONSHADOW RD
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21015-4999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-900-8897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. FOLASHADE KANIMODO
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 410-900-8897
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------