Provider Demographics
NPI:1538796735
Name:GREATER BALTIMORE BEHAVIORAL HEALTH SERVICES LLC
Entity type:Organization
Organization Name:GREATER BALTIMORE BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OLANREWAJU
Authorized Official - Middle Name:
Authorized Official - Last Name:ETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-600-4067
Mailing Address - Street 1:402 E 25TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5304
Mailing Address - Country:US
Mailing Address - Phone:410-889-3000
Mailing Address - Fax:410-889-3003
Practice Address - Street 1:402 E 25TH ST FL 1
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5304
Practice Address - Country:US
Practice Address - Phone:410-889-3000
Practice Address - Fax:410-889-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
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
MD4108893000Medicaid