Basic Information
| Provider Information | |||||||||
| NPI: | 1780659136 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOK LANE HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHRONIC ONSITE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13215 BROOK LANE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330330 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Practice Location | |||||||||
| Address1: | 13215 BROOK LANE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330330 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/31/2018 | ||||||||
| NPIReactivationDate: | 09/06/2022 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POFFENBERGER | ||||||||
| AuthorizedOfficialFirstName: | KRISTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COORDINATOR/MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 3017330331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 21-002 | MD | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 986965400 | 05 | MD | MEDICAID |