Provider Demographics
NPI:1275019580
Name:ISSIAIH HOUSE 1
Entity Type:Organization
Organization Name:ISSIAIH HOUSE 1
Other - Org Name:ISSAIAH HOUSE 1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BRAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LCADC
Authorized Official - Phone:443-882-1943
Mailing Address - Street 1:919 CALWELL RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5006
Mailing Address - Country:US
Mailing Address - Phone:443-882-1943
Mailing Address - Fax:
Practice Address - Street 1:2802 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-4953
Practice Address - Country:US
Practice Address - Phone:443-882-1943
Practice Address - Fax:410-558-6222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISSAIAH HOUSE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-19
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320600000X
MDBH000372324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities