=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497570402
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTHEM BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2024
-----------------------------------------------------
Last Update Date | 02/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 INTERNATIONAL CIR STE 230
-----------------------------------------------------
City | COCKEYSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21030-1344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-567-6091
-----------------------------------------------------
Fax | 443-567-6191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 N HICKORY AVE
-----------------------------------------------------
City | BEL AIR
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21014-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-459-7699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JENNIFER PETRIK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-567-6091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------