Provider Demographics
NPI:1508980251
Name:THE HOUSE OF THE GOOD SHEPHERD OF THE CITY OF BALTIMORE
Entity Type:Organization
Organization Name:THE HOUSE OF THE GOOD SHEPHERD OF THE CITY OF BALTIMORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:410-247-2770
Mailing Address - Street 1:4100 MAPLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-4007
Mailing Address - Country:US
Mailing Address - Phone:410-247-2770
Mailing Address - Fax:410-247-3242
Practice Address - Street 1:4100 MAPLE AVENUE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227-4007
Practice Address - Country:US
Practice Address - Phone:410-247-2770
Practice Address - Fax:410-247-3242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03-049322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD427825900Medicaid