Provider Demographics
NPI:1619485851
Name:FOREVER HOME, LLC
Entity Type:Organization
Organization Name:FOREVER HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SUBASIC
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, OTR/L, CPAS
Authorized Official - Phone:410-812-1916
Mailing Address - Street 1:PO BOX 652
Mailing Address - Street 2:
Mailing Address - City:MONKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21111-0652
Mailing Address - Country:US
Mailing Address - Phone:410-812-1916
Mailing Address - Fax:
Practice Address - Street 1:1324 RAYVILLE RD
Practice Address - Street 2:
Practice Address - City:PARKTON
Practice Address - State:MD
Practice Address - Zip Code:21120-9056
Practice Address - Country:US
Practice Address - Phone:443-212-5340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04200225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental ModificationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4245806Medicaid