Provider Demographics
NPI:1043952880
Name:A GLORIOUS PLACE LLC
Entity Type:Organization
Organization Name:A GLORIOUS PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLORY
Authorized Official - Middle Name:
Authorized Official - Last Name:TATAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-205-2458
Mailing Address - Street 1:3203A CORPORATE CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2247
Mailing Address - Country:US
Mailing Address - Phone:410-205-2458
Mailing Address - Fax:
Practice Address - Street 1:3203A CORPORATE CT
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2247
Practice Address - Country:US
Practice Address - Phone:410-205-2458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-12
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility