Basic Information
| Provider Information | |||||||||
| NPI: | 1215256417 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAUDENZIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4615 PARK HEIGHTS AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212156331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434231500 | ||||||||
| FaxNumber: | 4434231495 | ||||||||
| Practice Location | |||||||||
| Address1: | 4615 PARK HEIGHTS AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212156331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434231500 | ||||||||
| FaxNumber: | 4434231495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. CONTRACTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4843383731 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 903027 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 324500000X | 903027 | MD | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 405006100 | 05 | MD | MEDICAID |