1639424187 NPI number — SERENITY HEALTH, LLC

Table of content: MS. DIANE STANLEY LCSW, LCADC (NPI 1609936939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639424187 NPI number — SERENITY HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY HEALTH, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639424187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2873 TROYER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE HALL
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21161-9321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-504-3018
Provider Business Mailing Address Fax Number:
410-692-0143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
953 W PULASKI HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21921-4714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-485-6544
Provider Business Practice Location Address Fax Number:
443-485-6442
Provider Enumeration Date:
07/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TURNER
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
443-504-3018

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  904609 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 421677600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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