Provider Demographics
NPI:1891278024
Name:ISSAIAH HOUSE INC
Entity Type:Organization
Organization Name:ISSAIAH HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BRAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LCADC
Authorized Official - Phone:443-882-1943
Mailing Address - Street 1:919 CALWELL RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5006
Mailing Address - Country:US
Mailing Address - Phone:144-388-2194
Mailing Address - Fax:
Practice Address - Street 1:3808 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4221
Practice Address - Country:US
Practice Address - Phone:443-882-1943
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISSAIAH HOUSE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-13
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD250016700Medicaid