Provider Demographics
NPI:1609204999
Name:CHARM CITY THERAPY
Entity Type:Organization
Organization Name:CHARM CITY THERAPY
Other - Org Name:CHARM CITY THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OCCUPATION THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:404-502-6942
Mailing Address - Street 1:2405 STEELE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3924
Mailing Address - Country:US
Mailing Address - Phone:410-849-9496
Mailing Address - Fax:
Practice Address - Street 1:7 GWYNNS MILL CT STE I
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3528
Practice Address - Country:US
Practice Address - Phone:410-849-9496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-23
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
MD05807390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD050895100Medicaid