Provider Demographics
NPI:1528412590
Name:MISTAKEN IDENTITY CORPORATION
Entity Type:Organization
Organization Name:MISTAKEN IDENTITY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CHAIR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-298-5543
Mailing Address - Street 1:9701 APOLLO DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4783
Mailing Address - Country:US
Mailing Address - Phone:301-298-5543
Mailing Address - Fax:
Practice Address - Street 1:9701 APOLLO DR
Practice Address - Street 2:SUITE 301
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-4783
Practice Address - Country:US
Practice Address - Phone:301-298-5543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty