Provider Demographics
NPI:1043623465
Name:PORT RECOVERY, INC.
Entity Type:Organization
Organization Name:PORT RECOVERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRANRUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-534-8735
Mailing Address - Street 1:3410 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-2301
Mailing Address - Country:US
Mailing Address - Phone:410-534-8735
Mailing Address - Fax:410-534-8737
Practice Address - Street 1:3410 WHITE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-2301
Practice Address - Country:US
Practice Address - Phone:410-534-8735
Practice Address - Fax:410-534-8737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty