MEDICARE: DAVID'S LOFT CLINICAL PROGRAMS

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

General Provider Information

NPI Number	:	1285175273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID'S LOFT CLINICAL PROGRAMS

Provider Business Mailing Address
First Line	:	2641 MARYLAND AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-4518
Country	:	US
Telephone Number	:	410-800-4226
Fax Number	:

Provider Business Practice Location Address
First Line	:	2641 MARYLAND AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-4518
Country	:	US
Telephone Number	:	410-800-4226
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. DAVID HENRY THOMPSON JR.
Credential	:	LCPC
Telephone Number	:	410-800-4226

Provider Enumeration Date	:	03/10/2017
Last Update Date	:	02/15/2022

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