Provider Demographics
NPI:1942281423
Name:CHRYSALIS HOUSE INC
Entity Type:Organization
Organization Name:CHRYSALIS HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORENE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-974-6829
Mailing Address - Street 1:1570 CROWNSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-2306
Mailing Address - Country:US
Mailing Address - Phone:410-974-6829
Mailing Address - Fax:410-974-6350
Practice Address - Street 1:1570 CROWNSVILLE RD
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032-2306
Practice Address - Country:US
Practice Address - Phone:410-974-6829
Practice Address - Fax:410-974-6350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14717324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility