Provider Demographics
NPI:1437592938
Name:BOUNDLESS INNOVATIONS FOR HOLISTC LIVING
Entity Type:Organization
Organization Name:BOUNDLESS INNOVATIONS FOR HOLISTC LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOXWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-562-0605
Mailing Address - Street 1:1313 1/2 KENT AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-4829
Mailing Address - Country:US
Mailing Address - Phone:443-904-2412
Mailing Address - Fax:
Practice Address - Street 1:1500 UNION AVENUE
Practice Address - Street 2:SUITE 117
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-1975
Practice Address - Country:US
Practice Address - Phone:410-904-2412
Practice Address - Fax:443-817-0731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-15
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMH62251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health