Provider Demographics
NPI:1417928151
Name:BROOK LANE BEHAVIORAL SERVICES, INC.
Entity Type:Organization
Organization Name:BROOK LANE BEHAVIORAL SERVICES, INC.
Other - Org Name:NORTH VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:BARKDOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-733-0331
Mailing Address - Street 1:13121 BROOK LANE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1514
Mailing Address - Country:US
Mailing Address - Phone:301-733-0331
Mailing Address - Fax:301-733-4038
Practice Address - Street 1:18714 N VILLAGE
Practice Address - Street 2:SHOPPING CENTER
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2454
Practice Address - Country:US
Practice Address - Phone:301-733-0330
Practice Address - Fax:301-733-4038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12391261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD698800800Medicaid
MD698800800Medicaid