Provider Demographics
NPI:1437375615
Name:RONALD GRAY MEDLIN, INSTITUTE OF LIFE AND HEALTH
Entity Type:Organization
Organization Name:RONALD GRAY MEDLIN, INSTITUTE OF LIFE AND HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GRAY
Authorized Official - Last Name:MEDLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCADC
Authorized Official - Phone:301-627-3007
Mailing Address - Street 1:5311 WATER ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3056
Mailing Address - Country:US
Mailing Address - Phone:301-627-3007
Mailing Address - Fax:
Practice Address - Street 1:5311 WATER ST
Practice Address - Street 2:SUITE D
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3056
Practice Address - Country:US
Practice Address - Phone:301-627-3007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA352101YA0400X, 101YM0800X, 103T00000X, 103TA0400X, 103TF0000X, 103TH0100X, 106H00000X, 261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDGQ24RCOtherBLUECROSS BLUESHIELD