MEDICARE: ENTRO, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	324500000X	Substance Abuse Rehabilitation Facility
2	3245S0500X	Children's Substance Abuse Rehabilitation Facility
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1225779234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENTRO, LLC

Provider Business Mailing Address
First Line	:	4439 BELAIR RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21206-6337
Country	:	US
Telephone Number	:	410-262-6030
Fax Number	:

Provider Business Practice Location Address
First Line	:	4439 BELAIR RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21206-6337
Country	:	US
Telephone Number	:	410-262-6030
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. TONYIA GODLOCK
Credential	:	LMSW
Telephone Number	:	410-262-6030

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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Directions to “ENTRO, LLC ” Practice Location

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