Provider Demographics
NPI:1376701193
Name:THE HOUSE OF JUDE
Entity Type:Organization
Organization Name:THE HOUSE OF JUDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:AUGUSTSON
Authorized Official - Suffix:
Authorized Official - Credentials:NCC, LCPC, LCAD-C
Authorized Official - Phone:410-705-1331
Mailing Address - Street 1:P.O. BOX 5004
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220
Mailing Address - Country:US
Mailing Address - Phone:410-705-1331
Mailing Address - Fax:410-938-2237
Practice Address - Street 1:420 E. 25TH STREET
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218
Practice Address - Country:US
Practice Address - Phone:410-705-1331
Practice Address - Fax:410-938-2237
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE HOUSE OF JUDE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-29
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MDNCC-93405101YP2500X
MDLC-2284261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD414755300Medicaid
MD411699201Medicaid