Provider Demographics
NPI:1255861225
Name:UPPER BAY COUNSELING & SUPPORT SERVICES, INC
Entity Type:Organization
Organization Name:UPPER BAY COUNSELING & SUPPORT SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IT MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-996-3400
Mailing Address - Street 1:200 BOOTH ST
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5657
Mailing Address - Country:US
Mailing Address - Phone:410-996-3400
Mailing Address - Fax:410-398-3416
Practice Address - Street 1:1275B W PULASKI HWY
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-4719
Practice Address - Country:US
Practice Address - Phone:410-620-7161
Practice Address - Fax:410-398-3416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1989261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD922801201Medicaid