Provider Demographics
NPI:1609506815
Name:HERITAGE TREATMENT CENTER
Entity Type:Organization
Organization Name:HERITAGE TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-224-0655
Mailing Address - Street 1:4200 EDMONDSON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1600
Mailing Address - Country:US
Mailing Address - Phone:443-224-0655
Mailing Address - Fax:
Practice Address - Street 1:4200 EDMONDSON AVE STE 102
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1600
Practice Address - Country:US
Practice Address - Phone:443-224-0655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty