Provider Demographics
NPI:1154511236
Name:MAIN STREET MOBILE TREATMENT ASSOCIATES
Entity Type:Organization
Organization Name:MAIN STREET MOBILE TREATMENT ASSOCIATES
Other - Org Name:MAIN STREET COMMUNITY MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:410-654-6658
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:2007-07-26
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD749002000Medicaid