Provider Demographics
NPI:1477639631
Name:ADULT BEHAVIORAL HEALTH PROGRAM
Entity Type:Organization
Organization Name:ADULT BEHAVIORAL HEALTH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:INGATE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:240-777-1384
Mailing Address - Street 1:2424 REEDIE DR FL 3
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-4624
Mailing Address - Country:US
Mailing Address - Phone:240-777-1323
Mailing Address - Fax:240-777-3226
Practice Address - Street 1:2424 REEDIE DR FL 3
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MD
Practice Address - Zip Code:20902-4624
Practice Address - Country:US
Practice Address - Phone:240-777-1323
Practice Address - Fax:240-777-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD265391500302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDNONEOtherNONE
MDNONEOtherNONE