Provider Demographics
NPI:1568974608
Name:CREATED FOR GREATER PSYCHIATRIC REHABILITATION PROGRAM
Entity Type:Organization
Organization Name:CREATED FOR GREATER PSYCHIATRIC REHABILITATION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAKIA
Authorized Official - Middle Name:CHANTELL
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:LGSW
Authorized Official - Phone:443-220-2840
Mailing Address - Street 1:5411 OLD FREDERICK RD STE 8
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-2126
Mailing Address - Country:US
Mailing Address - Phone:443-315-5007
Mailing Address - Fax:
Practice Address - Street 1:5411 OLD FREDERICK RD STE 8
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-2126
Practice Address - Country:US
Practice Address - Phone:443-315-5007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health