1609924877 NPI number — COURAGE TO CHANGE OF SOUTHERN MARYLAND

Table of content: (NPI 1609924877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609924877 NPI number — COURAGE TO CHANGE OF SOUTHERN MARYLAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COURAGE TO CHANGE OF SOUTHERN MARYLAND
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:
Provider Other Organization Name Type Code:
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:
1609924877
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
96 ARMORY RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
PRINCE FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20678-4117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-414-9050
Provider Business Mailing Address Fax Number:
410-414-9060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
96 ARMORY RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PRINCE FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20678-4117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-414-9050
Provider Business Practice Location Address Fax Number:
410-414-9060
Provider Enumeration Date:
01/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HUMKE
Authorized Official First Name:
MARJORIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
410-414-9050

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LCA091 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD-10343401 . This is a "SAMIS ID" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com