Provider Demographics
NPI:1255701215
Name:AMERICAN CENTER FOR INTELLECTUAL AND DEVELOPMENTAL DISABILITIES IN MD
Entity type:Organization
Organization Name:AMERICAN CENTER FOR INTELLECTUAL AND DEVELOPMENTAL DISABILITIES IN MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:443-718-7031
Mailing Address - Street 1:8980 OLD ANNAPOLIS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2115
Mailing Address - Country:US
Mailing Address - Phone:443-319-5010
Mailing Address - Fax:
Practice Address - Street 1:300 THOMAS DR
Practice Address - Street 2:SUITE D
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4700
Practice Address - Country:US
Practice Address - Phone:301-377-0750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-03
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1658 1659251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health