Provider Demographics
NPI:1598234601
Name:PORT RECOVERY IOP INC.
Entity Type:Organization
Organization Name:PORT RECOVERY IOP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANRUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-534-8735
Mailing Address - Street 1:8615 RIDGELYS CHOICE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-3028
Mailing Address - Country:US
Mailing Address - Phone:410-534-8735
Mailing Address - Fax:410-534-8737
Practice Address - Street 1:8615 RIDGELYS CHOICE DR STE 205
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-3028
Practice Address - Country:US
Practice Address - Phone:443-869-4909
Practice Address - Fax:443-869-4928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-19
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD680402101Medicaid