Basic Information
| Provider Information | |||||||||
| NPI: | 1538657630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROOK LANE BEHAVIORAL SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13121 BROOK LANE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330330 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 BUCKEYSTOWN PIKE | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217048370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330330 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 10/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | BARKDOLL | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
| AuthorizedOfficialMiddleName: | LEA | ||||||||
| AuthorizedOfficialTitleorPosition: | CRED COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3017330331 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | BH000027 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.