=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952382665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POWELL RECOVERY CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2005
-----------------------------------------------------
Last Update Date | 10/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 S BROADWAY
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21231-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-276-1773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 S BROADWAY
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21231-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-276-1773
-----------------------------------------------------
Fax | 410-276-2056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MRS. KIM KRANTZ WIREMAN
-----------------------------------------------------
Credential | LCSW-C, LGADC
-----------------------------------------------------
Telephone | 410-276-1773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 103079
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------