1760644835 NPI number — MARYLAND TREATMENT CENTERS INC

Table of content: (NPI 1760644835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760644835 NPI number — MARYLAND TREATMENT CENTERS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYLAND TREATMENT CENTERS 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:
JOURNEYS ADOLESCENT PROGRAM
Provider Other Organization Name Type Code:
3
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:
1760644835
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14703 AVERY RD
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:
20853-3605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-762-5613
Provider Business Mailing Address Fax Number:
301-762-3451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14703 AVERY RD
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:
20853-3605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-294-4015
Provider Business Practice Location Address Fax Number:
301-294-4017
Provider Enumeration Date:
06/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROBY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
301-447-2361

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  15147 , 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: 391090300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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