Provider Demographics
NPI:1245629005
Name:I'M STILL STANDING BY GRACE
Entity type:Organization
Organization Name:I'M STILL STANDING BY GRACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:DUKES
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, CPC, CAC-AD
Authorized Official - Phone:443-831-0191
Mailing Address - Street 1:PO BOX 2727
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-0727
Mailing Address - Country:US
Mailing Address - Phone:443-831-0191
Mailing Address - Fax:410-355-3971
Practice Address - Street 1:1003 E PATAPSCO AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-2228
Practice Address - Country:US
Practice Address - Phone:443-831-0191
Practice Address - Fax:410-355-3971
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:I'M STILL STANDING BY GRACE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========Medicaid