MEDICARE: URBAN TRAUMA COUNSELING CENTER, 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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1144913625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	URBAN TRAUMA COUNSELING CENTER, LLC

Provider Business Mailing Address
First Line	:	3709 ESSEX RD
Second Line	:
City	:	PIKESVILLE
State	:	MD
Zip	:	21207-4617
Country	:	US
Telephone Number	:	410-960-2496
Fax Number	:

Provider Business Practice Location Address
First Line	:	2103 MOUNT HOLLY ST
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21216-2430
Country	:	US
Telephone Number	:	410-844-0770
Fax Number	:

Authorized Official
Title or Position	:	CEO/CLINICAL DIRECTOR
Name	:	SHINELLE OGLESBY
Credential	:	LCPC
Telephone Number	:	410-844-0770

Provider Enumeration Date	:	05/31/2023
Last Update Date	:	10/12/2023

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