Provider Demographics
NPI:1083286280
Name:HEAVENS PLACE-OUTPATIENT DETOX & RECOVERY CENTER
Entity Type:Organization
Organization Name:HEAVENS PLACE-OUTPATIENT DETOX & RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BISRAT
Authorized Official - Middle Name:
Authorized Official - Last Name:MESFIN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:443-708-5612
Mailing Address - Street 1:11 E LEXINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-1720
Mailing Address - Country:US
Mailing Address - Phone:443-708-5612
Mailing Address - Fax:410-826-3855
Practice Address - Street 1:11 E LEXINGTON ST STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-1720
Practice Address - Country:US
Practice Address - Phone:443-708-5612
Practice Address - Fax:410-826-3855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder