Provider Demographics
NPI:1114566973
Name:GALLERY OF MINDS
Entity Type:Organization
Organization Name:GALLERY OF MINDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PROFESSIONAL
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:BELISE
Authorized Official - Last Name:GREEN RANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-415-5075
Mailing Address - Street 1:4015 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-2916
Mailing Address - Country:US
Mailing Address - Phone:443-415-5075
Mailing Address - Fax:
Practice Address - Street 1:3426 BELAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1233
Practice Address - Country:US
Practice Address - Phone:443-763-3718
Practice Address - Fax:410-325-9198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)