1871983320 NPI number — BROOK LANE BEHAVIORAL SERVICES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871983320 NPI number — BROOK LANE BEHAVIORAL SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOK LANE BEHAVIORAL SERVICES, INC.
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:
1871983320
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13121 BROOK LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAGERSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21742-1435
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-733-0330
Provider Business Mailing Address Fax Number:
301-733-4038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4540 B-D MACK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-733-0330
Provider Business Practice Location Address Fax Number:
301-733-4038
Provider Enumeration Date:
02/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BARKDOLL
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
LEA
Authorized Official Title or Position:
CRED COORDINATOR
Authorized Official Telephone Number:
301-733-0331

Provider Taxonomy Codes

  • Taxonomy code: 101YS0200X , with the licence number:  4010 , 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)





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