Provider Demographics
NPI:1164883344
Name:MISHA HOUSE, LLC
Entity Type:Organization
Organization Name:MISHA HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CAC-AD
Authorized Official - Phone:443-708-3054
Mailing Address - Street 1:2300 GARRISON BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216
Mailing Address - Country:US
Mailing Address - Phone:443-708-3054
Mailing Address - Fax:443-708-4402
Practice Address - Street 1:2300 GARRISON BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216
Practice Address - Country:US
Practice Address - Phone:443-708-3054
Practice Address - Fax:443-708-4402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QR0405X261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder