Provider Demographics
NPI:1033101738
Name:JOHN L. GILDNER REGIONAL INSTITUTE FOR CHILDREN AND ADOLESCENTS
Entity Type:Organization
Organization Name:JOHN L. GILDNER REGIONAL INSTITUTE FOR CHILDREN AND ADOLESCENTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PERFORMANCE IMPROVEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:AVERY
Authorized Official - Last Name:KNIFFEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MBA
Authorized Official - Phone:301-251-6828
Mailing Address - Street 1:15000 BROSCHART RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3303
Mailing Address - Country:US
Mailing Address - Phone:301-251-6800
Mailing Address - Fax:301-309-9004
Practice Address - Street 1:15000 BROSCHART RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3303
Practice Address - Country:US
Practice Address - Phone:301-251-6800
Practice Address - Fax:301-309-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15-038322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children