Provider Demographics
NPI:1629629670
Name:VINCENT G. BANKS CENTER FOR RESIDENTIAL SUBSTANCE USE TREATMENT
Entity Type:Organization
Organization Name:VINCENT G. BANKS CENTER FOR RESIDENTIAL SUBSTANCE USE TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:410-800-4226
Mailing Address - Street 1:2641 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-4518
Mailing Address - Country:US
Mailing Address - Phone:410-800-4226
Mailing Address - Fax:
Practice Address - Street 1:12 E EAGER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2514
Practice Address - Country:US
Practice Address - Phone:410-800-4226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-21
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD502387400Medicaid