Basic Information
| Provider Information | |||||||||
| NPI: | 1982081154 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BONFIRE BEHAVIORAL HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10019 REISTERSTOWN RD FL 3 | ||||||||
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| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211173902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108078471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10 GROVE ST | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038203334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036173399 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2015 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | BUTLER | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF LCC | ||||||||
| AuthorizedOfficialTelephone: | 8176028218 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 3127880 | 05 | NH | MEDICAID | 3103840 | 05 | NH | MEDICAID |