=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679923056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODBOURNE SCHOOL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2016
-----------------------------------------------------
Last Update Date | 06/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 WOODBOURNE AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21239-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-433-1000
-----------------------------------------------------
Fax | 410-433-1459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 WOODBOURNE AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21239-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-433-1000
-----------------------------------------------------
Fax | 410-433-1459
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. ANTHONY WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-433-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number | 3875
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------