Provider Demographics
NPI:1063721512
Name:BROOK LANE BEHAVIORAL SERVICES, INC.
Entity type:Organization
Organization Name:BROOK LANE BEHAVIORAL SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:REPAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-790-9351
Mailing Address - Street 1:4540 MACK AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-3303
Mailing Address - Country:US
Mailing Address - Phone:301-733-0330
Mailing Address - Fax:301-733-4038
Practice Address - Street 1:4540 MACK AVE STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-3303
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:2010-10-01
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD698800805Medicaid