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NPI Code Detail

MEDICARE: PORT RECOVERY IOP INC.

MEDICARE: PORT RECOVERY IOP INC.
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
1101YP2500XProfessional Counselor
21041C0700XClinical Social Worker
32084P0800XPsychiatry Physician
4363LP0808XPsychiatric/Mental Health Nurse Practitioner
5101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1578026464
Entity Type Code : Organization
Provider Name (Legal Business Name) : PORT RECOVERY IOP INC.
Provider Business Mailing Address
First Line : 8615 RIDGELYS CHOICE DR STE 205
Second Line :
City : NOTTINGHAM
State : MD
Zip : 21236-3028
Country : US
Telephone Number : 443-869-4909
Fax Number : 443-869-4928
Provider Business Practice Location Address
First Line : 8615 RIDGELYS CHOICE DR STE 205
Second Line :
City : NOTTINGHAM
State : MD
Zip : 21236-3028
Country : US
Telephone Number : 443-869-4909
Fax Number : 443-869-4928
Authorized Official
Title or Position : OWNER
Name : JOANNE GRANRUTH
Credential :
Telephone Number : 410-534-8735
Provider Enumeration Date : 04/09/2019
Last Update Date : 04/09/2019

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