Provider Demographics
NPI:1265011928
Name:GRACELAND PSYCHIATRY LLC
Entity Type:Organization
Organization Name:GRACELAND PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ADETIMBO
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEDIRAN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:240-722-9763
Mailing Address - Street 1:9435 PARAGON CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-1408
Mailing Address - Country:US
Mailing Address - Phone:240-722-9763
Mailing Address - Fax:
Practice Address - Street 1:10451 MILL RUN CIR
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5577
Practice Address - Country:US
Practice Address - Phone:888-517-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-07
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty