Provider Demographics
NPI:1023200227
Name:INTEGRATIVE HEALTH CLINIC
Entity Type:Organization
Organization Name:INTEGRATIVE HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-764-7777
Mailing Address - Street 1:3601 CLARKS LN
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-2731
Mailing Address - Country:US
Mailing Address - Phone:410-764-7777
Mailing Address - Fax:410-764-7788
Practice Address - Street 1:3601 CLARKS LN
Practice Address - Street 2:SUITE 5A
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-2731
Practice Address - Country:US
Practice Address - Phone:410-764-7777
Practice Address - Fax:410-764-7788
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR GAV LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM132101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty