Provider Demographics
NPI:1891033916
Name:MARYLAND PSYCHOLOGICAL AND MANAGEMENT SERVICES CENTER, LLC
Entity Type:Organization
Organization Name:MARYLAND PSYCHOLOGICAL AND MANAGEMENT SERVICES CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DURWOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:443-438-7863
Mailing Address - Street 1:10 W MADISON ST # 11
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5239
Mailing Address - Country:US
Mailing Address - Phone:443-438-7863
Mailing Address - Fax:443-957-9485
Practice Address - Street 1:10 W MADISON ST # 11
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5239
Practice Address - Country:US
Practice Address - Phone:443-438-7863
Practice Address - Fax:443-957-9485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04983261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD052304600Medicaid