Provider Demographics
NPI:1568096428
Name:ISSIAIH HOUSE 1
Entity Type:Organization
Organization Name:ISSIAIH HOUSE 1
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, LCADC
Authorized Official - Phone:443-882-1943
Mailing Address - Street 1:4313 BRIGGS CHANEY RD
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1044
Mailing Address - Country:US
Mailing Address - Phone:443-882-1943
Mailing Address - Fax:
Practice Address - Street 1:2301 DORSEY RD
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3299
Practice Address - Country:US
Practice Address - Phone:443-882-1943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISSAIAH HOUSE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty