Provider Demographics
NPI:1487862181
Name:BROOK LANE HEALTH SERVICES
Entity type:Organization
Organization Name:BROOK LANE HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR/MANAGED CARE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKDOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-733-0331
Mailing Address - Street 1:13121 BROOKLANE DR
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1514
Mailing Address - Country:US
Mailing Address - Phone:301-733-0330
Mailing Address - Fax:301-733-4038
Practice Address - Street 1:13218 BROOKLANE DR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-733-0330
Practice Address - Fax:301-733-4038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD986965400Medicaid