=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447996145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENTRO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2022
-----------------------------------------------------
Last Update Date | 05/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4439 BELAIR RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21206-6337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-617-8043
-----------------------------------------------------
Fax | 410-624-5738
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4439 BELAIR RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21206-6337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-617-8043
-----------------------------------------------------
Fax | 410-624-5738
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. TONYIA GODLOCK
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 410-617-8043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------