Provider Demographics
NPI:1356839021
Name:BROOKLYN FAMILY SERVICE INSTITUTE
Entity Type:Organization
Organization Name:BROOKLYN FAMILY SERVICE INSTITUTE
Other - Org Name:BROOKLYN FAMILY SERVICE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C,LCMFT,LCADC-S
Authorized Official - Phone:301-512-4689
Mailing Address - Street 1:1300 MERCANTILE LN STE 136C
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5332
Mailing Address - Country:US
Mailing Address - Phone:301-512-4689
Mailing Address - Fax:
Practice Address - Street 1:1004 E PATAPSCO AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MD
Practice Address - Zip Code:21225-2229
Practice Address - Country:US
Practice Address - Phone:301-512-4689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD098501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD688703100Medicaid