Provider Demographics
NPI:1235749771
Name:TARGET BEHAVIORAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:TARGET BEHAVIORAL HEALTH SERVICES, LLC
Other - Org Name:TARGET BEHAVIORAL HEALTH SERVICES, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FOLASHADE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANIMODO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:410-900-8897
Mailing Address - Street 1:1415 MOONSHADOW RD
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-4999
Mailing Address - Country:US
Mailing Address - Phone:410-900-8897
Mailing Address - Fax:
Practice Address - Street 1:1415 MOONSHADOW RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-4999
Practice Address - Country:US
Practice Address - Phone:410-900-8897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-07
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty