Provider Demographics
NPI:1407284995
Name:TAKE CHARGE JUVENILE DIVERSION PROGRAM, INC.
Entity Type:Organization
Organization Name:TAKE CHARGE JUVENILE DIVERSION PROGRAM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRAH
Authorized Official - Middle Name:JERROD
Authorized Official - Last Name:MUSTAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-420-7395
Mailing Address - Street 1:7610 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORESTVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20747-4701
Mailing Address - Country:US
Mailing Address - Phone:301-420-7395
Mailing Address - Fax:301-420-7397
Practice Address - Street 1:7610 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FORESTVILLE
Practice Address - State:MD
Practice Address - Zip Code:20747-4701
Practice Address - Country:US
Practice Address - Phone:301-420-7395
Practice Address - Fax:301-420-7397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management