1386620581 NPI number — WILLOW OAK THERAPY CENTER, INC.

Table of Contents

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:
Provider Other Organization Name Type Code:
6
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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