Provider Demographics
NPI:1891185658
Name:BROOK LANE HEALTH SERVICES/LAUREL HALL
Entity Type:Organization
Organization Name:BROOK LANE HEALTH SERVICES/LAUREL HALL
Other - Org Name:LAUREL HALL SCHOOL
Other - Org Type:Other Name
Authorized Official - Title/Position:COORDINATOR/MANAGED CARE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:POFFENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-733-0331
Mailing Address - Street 1:13310-A BROOK LANE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1514
Mailing Address - Country:US
Mailing Address - Phone:301-733-0330
Mailing Address - Fax:301-733-4038
Practice Address - Street 1:13310-A BROOK LANE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-1514
Practice Address - Country:US
Practice Address - Phone:301-733-0330
Practice Address - Fax:301-733-4038
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOK LANE HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-02
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3852101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD568605900Medicaid