Provider Demographics
NPI:1659316636
Name:MENTOR MD
Entity Type:Organization
Organization Name:MENTOR MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MATRICARDI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW - C
Authorized Official - Phone:443-543-2101
Mailing Address - Street 1:4501 FORBES BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-4326
Mailing Address - Country:US
Mailing Address - Phone:301-459-3057
Mailing Address - Fax:301-731-3142
Practice Address - Street 1:4501 FORBES BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4326
Practice Address - Country:US
Practice Address - Phone:301-459-3057
Practice Address - Fax:301-731-3142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2012261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health