Provider Demographics
NPI:1124223979
Name:COLLINGTON SQUARE NON PROFIT CORPORATION
Entity Type:Organization
Organization Name:COLLINGTON SQUARE NON PROFIT CORPORATION
Other - Org Name:BERNICE E. MEADE HOUSE OF SAFE HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEWEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:410-342-6858
Mailing Address - Street 1:1211 N CHESTER ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-3330
Mailing Address - Country:US
Mailing Address - Phone:410-342-6858
Mailing Address - Fax:
Practice Address - Street 1:1211 N CHESTER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-3330
Practice Address - Country:US
Practice Address - Phone:410-342-6858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1014663245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD101466OtherSAMIS NO