Provider Demographics
NPI:1497306443
Name:DAVID'S LOFT CLINICAL PROGRAMS
Entity Type:Organization
Organization Name:DAVID'S LOFT CLINICAL PROGRAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-800-4226
Mailing Address - Street 1:2641 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-4518
Mailing Address - Country:US
Mailing Address - Phone:410-800-4226
Mailing Address - Fax:
Practice Address - Street 1:2641 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-4518
Practice Address - Country:US
Practice Address - Phone:410-800-4226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD908601300Medicaid