Provider Demographics
NPI:1619694239
Name:PUDDS PLACE
Entity Type:Organization
Organization Name:PUDDS PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SYKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:CAC-AD-BAS, LMSW
Authorized Official - Phone:443-633-3177
Mailing Address - Street 1:3018 AUTUMN BRANCH LN APT E
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3514
Mailing Address - Country:US
Mailing Address - Phone:443-633-3177
Mailing Address - Fax:
Practice Address - Street 1:2413 REISTERSTOWN RD APT 1
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-2056
Practice Address - Country:US
Practice Address - Phone:443-633-3177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1093103756Medicaid