=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447231576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALTIMORE COMMUNITY RESOURCE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2005
-----------------------------------------------------
Last Update Date | 07/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 W 25TH ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-366-1717
-----------------------------------------------------
Fax | 410-889-4167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 W 25TH ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-366-1717
-----------------------------------------------------
Fax | 410-889-4167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. ROBIN WOODELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-366-1717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 13138
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------