| NPI | 1275235103 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JESSIE COSTLEY Credentialing Specialist 443-839-6928 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0850X Clinic/Center, Adult Mental Health |
| Additional Taxonomies | 207QA0401X Family Medicine, Addiction Medicine |
| 363L00000X Nurse Practitioner | |
| Enumeration Date | 2023-03-22 |
| Last Update Date | 2025-01-20 |