Organization
FREESTATE BEHAVIORAL HEALTH ASSOCIATES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DWIGHT A POLK LCSW-C (OWNER)
(443) 695-7851
Entity
Organization
Contact information
Practice address
3455 WILKENS AVE STE 301, BALTIMORE, MD 21229-5214
(443) 695-7851
Mailing address
3455 WILKENS AVE STE 301, BALTIMORE, MD 21229-5214
(443) 695-7851
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
18559
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1356866768
TYPE 1 INDIVIDUAL NPI #
MD
01
—
338300
JHHC ID #
MD
01
—
601222437
MAGELLAN ID #
MD
01
—
6018524
AETNA PIN #
MD
01
—
CR20-0007
CAREFIRST BCBS
MD
Enumeration date
02/22/2018
Last updated
02/22/2018
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