Basic Information
| Provider Information | |||||||||
| NPI: | 1073106274 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BONFIRE BEHAVIORAL HEALTH LLC | ||||||||
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| OtherOrganizationName: | NEW HAMPSHIRE DETOX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10019 REISTERSTOWN RD FL 3 | ||||||||
| Address2: | |||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211173902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108078471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2957 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108078471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2021 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4438396928 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 3127887 | 05 | NH | MEDICAID |