MEDICARE: EDEN PLACE HEALING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1063399012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN PLACE HEALING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2602
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-0003
Country	:	US
Telephone Number	:	443-674-6343
Fax Number	:

Provider Business Practice Location Address
First Line	:	3911 FAIRVIEW AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21216-1229
Country	:	US
Telephone Number	:	443-674-6343
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LOVELY MOULTON
Credential	:	LCPC, LCADC
Telephone Number	:	443-674-6343

Provider Enumeration Date	:	08/20/2025
Last Update Date	:	08/20/2025

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Directions to “EDEN PLACE HEALING, LLC ” Practice Location

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