1790156362 NPI number — THRIVE BEHAVIORAL HEALTH, LLC

Table of content: (NPI 1790156362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790156362 NPI number — THRIVE BEHAVIORAL HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THRIVE BEHAVIORAL 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:
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:
1790156362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9627 PHILADELPHIA RD STE 160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEDALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21237-4157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-780-5203
Provider Business Mailing Address Fax Number:
410-780-5205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5720 EXECUTIVE DR STE 100-105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-780-5203
Provider Business Practice Location Address Fax Number:
410-780-5205
Provider Enumeration Date:
10/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HYMEL
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
410-780-5203

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  MH-1669 , 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: 4223195-02 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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