Provider Demographics
NPI:1619385630
Name:MAIN PLACE ADDICTION TREATMENT CENTER LLC.
Entity Type:Organization
Organization Name:MAIN PLACE ADDICTION TREATMENT CENTER LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-575-1324
Mailing Address - Street 1:365 W PATRICK ST STE 202
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4854
Mailing Address - Country:US
Mailing Address - Phone:240-575-1324
Mailing Address - Fax:301-682-2053
Practice Address - Street 1:915 TOLL HOUSE AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-5930
Practice Address - Country:US
Practice Address - Phone:240-575-1324
Practice Address - Fax:301-682-2053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD319411600Medicaid