MEDICARE: FORMATIONS HEALTH

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	:	1922852862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORMATIONS HEALTH

Provider Business Mailing Address
First Line	:	710 N HAMMONDS FERRY RD
Second Line	:
City	:	LINTHICUM HEIGHTS
State	:	MD
Zip	:	21090-1313
Country	:	US
Telephone Number	:	410-636-7057
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 N HAMMONDS FERRY RD
Second Line	:
City	:	LINTHICUM HEIGHTS
State	:	MD
Zip	:	21090-1313
Country	:	US
Telephone Number	:	410-636-7057
Fax Number	:

Authorized Official
Title or Position	:	CEO OF FORMATIONS HEALTH
Name	:	MRS. TEKESHA M TYSON
Credential	:
Telephone Number	:	443-846-9239

Provider Enumeration Date	:	04/16/2024
Last Update Date	:	04/16/2024

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