Provider Demographics
NPI: | 1508811936 |
---|---|
Name: | MARYLAND TREATMENT CENTERS, INC. |
Entity Type: | Organization |
Organization Name: | MARYLAND TREATMENT CENTERS, INC. |
Other - Org Name: | MOUNTAIN MANOR TREATMENT CENTERS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | EXECUTIVE VICE PRESIDENT |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | BARBARA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GROVES |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MED |
Authorized Official - Phone: | 410-233-1400 |
Mailing Address - Street 1: | 3800 FREDERICK AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | BALTIMORE |
Mailing Address - State: | MD |
Mailing Address - Zip Code: | 21229-3618 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 410-233-1400 |
Mailing Address - Fax: | 410-233-5583 |
Practice Address - Street 1: | 3800 FREDERICK AVE |
Practice Address - Street 2: | |
Practice Address - City: | BALTIMORE |
Practice Address - State: | MD |
Practice Address - Zip Code: | 21229-3618 |
Practice Address - Country: | US |
Practice Address - Phone: | 410-233-1400 |
Practice Address - Fax: | 410-233-5583 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-05-24 |
Last Update Date: | 2011-03-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | 2084A0401X, 2084P0800X, 2084P0802X, 2084P0804X | |
MD | 3799 | 251300000X |
MD | 14077 | 261QM0801X, 261QM0850X, 261QM0855X |
MD | 903139 | 261QR0405X |
MD | 903143 | 261QR0405X |
MD | 903140 | 324500000X, 3245S0500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | ||
No | 2084A0401X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | Group - Single Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Single Specialty |
No | 2084P0802X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | Group - Single Specialty |
No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Single Specialty |
No | 251300000X | Agencies | Local Education Agency (LEA) | ||
No | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | |
No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | |
No | 261QR0405X | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | |
No | 3245S0500X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MD | 090501100 | Medicaid | |
MD | 203102700 | Medicaid | |
MD | 510126302 | Medicaid | |
MO | 774502800 | Medicaid | |
MD | 039155700 | Medicaid | |
MD | 391090301 | Medicaid |