Provider Demographics
NPI:1033761325
Name:FOUNTAIN OF LIFE BEHAVIORAL HEALTH COUNSELING & WELLNESS CTR.
Entity Type:Organization
Organization Name:FOUNTAIN OF LIFE BEHAVIORAL HEALTH COUNSELING & WELLNESS CTR.
Other - Org Name:FOUNTAIN OF LIFE BEHAVIORAL HEALTH COUNSELING & WELLNESS CTR.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARRIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,LCPC,GPP
Authorized Official - Phone:443-558-8933
Mailing Address - Street 1:3704 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-1313
Mailing Address - Country:US
Mailing Address - Phone:443-558-8933
Mailing Address - Fax:443-965-9523
Practice Address - Street 1:3704 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-1313
Practice Address - Country:US
Practice Address - Phone:443-558-8933
Practice Address - Fax:443-965-9523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-16
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD07162019328804Medicaid