Provider Demographics
NPI:1134139637
Name:MAIN STREET MOBILE TREATMENT ASSOCIATES INC
Entity Type:Organization
Organization Name:MAIN STREET MOBILE TREATMENT ASSOCIATES INC
Other - Org Name:MAIN STREET COMMUNITY MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:410-526-7882
Mailing Address - Street 1:37 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-1236
Mailing Address - Country:US
Mailing Address - Phone:410-526-7882
Mailing Address - Fax:410-526-9855
Practice Address - Street 1:37 MAIN ST
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-1236
Practice Address - Country:US
Practice Address - Phone:410-526-7882
Practice Address - Fax:410-526-9855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404353700Medicaid
MD017NMedicare ID - Type UnspecifiedMEDICARE