Provider Demographics
NPI:1518551415
Name:SEVERIN GREEN BEHAVIORAL HEALTH, LLC
Entity Type:Organization
Organization Name:SEVERIN GREEN BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-632-6520
Mailing Address - Street 1:6701 QUEENS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-1429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6701 QUEENS FERRY RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-1429
Practice Address - Country:US
Practice Address - Phone:443-743-2280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty