Provider Demographics
NPI:1912793043
Name:SELF RESTORATIVE SERVICES LLC
Entity type:Organization
Organization Name:SELF RESTORATIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SYDNEY-SHIANN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-968-2809
Mailing Address - Street 1:218 COLLINS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-3611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:218 COLLINS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-3611
Practice Address - Country:US
Practice Address - Phone:240-968-2809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty