=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467973081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTE FOR FAITH BASED LEADERSHIP & PHILANTHROPY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3311 BATEMAN AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21216-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-908-0063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3311 BATEMAN AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21216-1807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-908-0063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | THERESA HARRIS
-----------------------------------------------------
Credential | M. ED, LCPC
-----------------------------------------------------
Telephone | 410-908-0063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LC7958
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LC7958
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------