Provider Demographics
NPI:1942570353
Name:HOUSE OF THE GOOD SHEPHERD CORPORATION
Entity Type:Organization
Organization Name:HOUSE OF THE GOOD SHEPHERD CORPORATION
Other - Org Name:GOOD SHEPHERD SCHOOL
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-247-2770
Mailing Address - Street 1:4100 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-4007
Mailing Address - Country:US
Mailing Address - Phone:410-247-2770
Mailing Address - Fax:
Practice Address - Street 1:4100 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227-4007
Practice Address - Country:US
Practice Address - Phone:410-247-2770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD427825900Medicaid