Provider Demographics
NPI:1730903220
Name:BOOTSIE CENTER, LLC
Entity type:Organization
Organization Name:BOOTSIE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW-C
Authorized Official - Prefix:
Authorized Official - First Name:RAKEEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COMMODORE-JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-474-6546
Mailing Address - Street 1:1925 SCIENTISTS CLIFFS RD
Mailing Address - Street 2:
Mailing Address - City:PORT REPUBLIC
Mailing Address - State:MD
Mailing Address - Zip Code:20676-2405
Mailing Address - Country:US
Mailing Address - Phone:410-474-6546
Mailing Address - Fax:
Practice Address - Street 1:1925 SCIENTISTS CLIFFS RD
Practice Address - Street 2:
Practice Address - City:PORT REPUBLIC
Practice Address - State:MD
Practice Address - Zip Code:20676-2405
Practice Address - Country:US
Practice Address - Phone:410-474-6546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health