MEDICARE: GAUDENZIA.ORG

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	324500000X	Substance Abuse Rehabilitation Facility	904854	MD

General Provider Information

NPI Number	:	1376886721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAUDENZIA.ORG

Provider Business Mailing Address
First Line	:	4615 PARK HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-6331
Country	:	US
Telephone Number	:	410-367-4447
Fax Number	:	410-367-4447

Provider Business Practice Location Address
First Line	:	4615 PARK HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-6331
Country	:	US
Telephone Number	:	410-367-4447
Fax Number	:	410-367-4447

Authorized Official
Title or Position	:	SR. CONTRACTING MANAGER
Name	:	MIKE WILLIAMS
Credential	:
Telephone Number	:	484-338-3731

Provider Enumeration Date	:	04/04/2013
Last Update Date	:	06/24/2021

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Directions to “GAUDENZIA.ORG ” Practice Location

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