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General NPI Number Information
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NPI Number | 1487155776
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Entity Type | Organization
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Legal Business Name | FREESTATE BEHAVIORAL HEALTH ASSOCIATES LLC
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Dates
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Enumeration Date | 02/22/2018
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Last Update Date | 02/22/2018
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Provider Practice Location Address
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Address Line | 3455 WILKENS AVE STE 301
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City | BALTIMORE
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State | MD
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Zip | 21229-5214
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Country | US
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Telephone | 443-695-7851
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Fax |
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Provider Business Mailing Address
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Address Line | 3455 WILKENS AVE STE 301
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City | BALTIMORE
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State | MD
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Zip | 21229-5214
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Country | US
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Telephone | 443-695-7851
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DWIGHT A POLK
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Credential | LCSW-C
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Telephone | 443-695-7851
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 18559
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License Number State | MD
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