Provider Demographics
NPI:1104105329
Name:NATIVE AMERICAN LIFELINES, INC.
Entity type:Organization
Organization Name:NATIVE AMERICAN LIFELINES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:410-934-0636
Mailing Address - Street 1:1 E FRANKLIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2239
Mailing Address - Country:US
Mailing Address - Phone:410-837-2258
Mailing Address - Fax:410-837-2692
Practice Address - Street 1:106 CLAY ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-3501
Practice Address - Country:US
Practice Address - Phone:410-837-2258
Practice Address - Fax:410-837-2692
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIVE AMERICAN LIFELINES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-04
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD904244251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health