Provider Demographics
NPI:1265918288
Name:ST. JOHN'S COMMUNITY SERVICES MARYLAND
Entity type:Organization
Organization Name:ST. JOHN'S COMMUNITY SERVICES MARYLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF STRATEGIC INITIATIVES OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-592-2842
Mailing Address - Street 1:2201 WISCONSIN AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-4105
Mailing Address - Country:US
Mailing Address - Phone:202-237-6391
Mailing Address - Fax:202-237-6352
Practice Address - Street 1:1406 MERGANSER CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-7021
Practice Address - Country:US
Practice Address - Phone:301-218-0915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOHN'S COMMUNITY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities