Provider Demographics
NPI:1952382665
Name:POWELL RECOVERY CENTER, INC.
Entity type:Organization
Organization Name:POWELL RECOVERY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:KRANTZ
Authorized Official - Last Name:WIREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C, LGADC
Authorized Official - Phone:410-276-1773
Mailing Address - Street 1:14 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-1712
Mailing Address - Country:US
Mailing Address - Phone:410-276-1773
Mailing Address - Fax:410-276-2056
Practice Address - Street 1:16 S BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1712
Practice Address - Country:US
Practice Address - Phone:410-276-1773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD103079261QR0405X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218121500Medicaid
MD415783400Medicaid