Provider Demographics
NPI:1518563022
Name:ISSAIAH HOUSE INC
Entity Type:Organization
Organization Name:ISSAIAH HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-882-1943
Mailing Address - Street 1:919 CALWELL RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5006
Mailing Address - Country:US
Mailing Address - Phone:443-882-1943
Mailing Address - Fax:410-558-6222
Practice Address - Street 1:919 CALWELL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5006
Practice Address - Country:US
Practice Address - Phone:443-882-1943
Practice Address - Fax:410-558-6222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISSAIAH HOUSE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-09
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD160026500Medicaid