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General NPI Number Information
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NPI Number | 1780495002
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Entity Type | Organization
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Legal Business Name | MARYLAND RECOVERY HOMES LLC
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Dates
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Enumeration Date | 01/16/2025
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Last Update Date | 01/16/2025
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Provider Practice Location Address
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Address Line | 3812 CHESLEY AVE
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City | BALTIMORE
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State | MD
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Zip | 21206-1509
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Country | US
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Telephone | 410-215-2619
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Fax |
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Provider Business Mailing Address
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Address Line | 3812 CHESLEY AVE
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City | BALTIMORE
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State | MD
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Zip | 21206-1509
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Country | US
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Telephone | 410-215-2619
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | KATHERINE JANESTA KELLEY
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Credential |
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Telephone | 410-215-2619
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Legacy Identifiers
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Identifier #1
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Identifier Code | 1000142723
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Identifier Type | MEDICAID
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Identifier State | MD
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Identifier Issuer |
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Identifier #2
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Identifier Code | 1000051637
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Identifier Type | MEDICAID
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Identifier State | MD
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Identifier Issuer |
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Identifier #3
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Identifier Code | 1000051629
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Identifier Type | MEDICAID
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Identifier State | MD
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Identifier Issuer |
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Identifier #4
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Identifier Code | 1000054548
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Identifier Type | MEDICAID
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Identifier State | MD
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Identifier Issuer |
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 1000051629
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Identifier Type | MEDICAID
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Identifier State | MD
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Identifier Issuer |
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Identifier #2
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Identifier Code | 1000051637
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Identifier Type | MEDICAID
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Identifier State | MD
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Identifier Issuer |
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Identifier #3
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Identifier Code | 1000054548
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Identifier Type | MEDICAID
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Identifier State | MD
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Identifier Issuer |
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Identifier #4
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Identifier Code | 1000142723
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Identifier Type | MEDICAID
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Identifier State | MD
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Identifier Issuer |
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