=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770307746
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICIA'S PLACE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2024
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3234 BELAIR RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21213-1228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-979-7501
-----------------------------------------------------
Fax | 301-979-7638
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5006 ASHMANS HOPE
-----------------------------------------------------
City | GWYNN OAK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21207-6500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-979-7501
-----------------------------------------------------
Fax | 301-979-7638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. TIFFANI A WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-979-7501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------