Provider Demographics
NPI:1275121113
Name:LIFE MANAGEMENT OF MARYLAND
Entity Type:Organization
Organization Name:LIFE MANAGEMENT OF MARYLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JERILISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:443-880-7859
Mailing Address - Street 1:209 W JEWELL ST
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:DE
Mailing Address - Zip Code:19940-1008
Mailing Address - Country:US
Mailing Address - Phone:443-880-7859
Mailing Address - Fax:
Practice Address - Street 1:209 E MARKET ST STE 10A
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-4992
Practice Address - Country:US
Practice Address - Phone:443-503-3481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD131585401Medicaid