1386620581 NPI number — WILLOW OAK THERAPY CENTER, INC.

Table of content: (NPI 1386620581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386620581 NPI number — WILLOW OAK THERAPY CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOW OAK THERAPY CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AFFILIATED COMMUNITY COUNSELORS, INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386620581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15701 CRABBS BRANCH WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20855-2634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-251-8965
Provider Business Mailing Address Fax Number:
301-251-0136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15701 CRABBS BRANCH WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20855-2634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-251-8965
Provider Business Practice Location Address Fax Number:
301-251-0136
Provider Enumeration Date:
12/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
THAYER
Authorized Official First Name:
JODY
Authorized Official Middle Name:
TABNER
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
301-251-8965

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 125603300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7726 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 5458AF . This is a "BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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