Provider Demographics
NPI:1710357447
Name:OPERATION WARRIOR REFUGE, INC
Entity Type:Organization
Organization Name:OPERATION WARRIOR REFUGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:240-298-6680
Mailing Address - Street 1:PO BOX 733
Mailing Address - Street 2:
Mailing Address - City:GREAT MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20634-0733
Mailing Address - Country:US
Mailing Address - Phone:301-880-0531
Mailing Address - Fax:
Practice Address - Street 1:25420 ROSEDALE MANOR LN
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:MD
Practice Address - Zip Code:20636-2925
Practice Address - Country:US
Practice Address - Phone:301-880-0531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5662101YM0800X, 251S00000X
MD05590103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty