Provider Demographics
NPI:1396525291
Name:IMPERIAL MENTORING
Entity type:Organization
Organization Name:IMPERIAL MENTORING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:410-702-8864
Mailing Address - Street 1:7040 MATTHIAS ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3212
Mailing Address - Country:US
Mailing Address - Phone:410-702-8864
Mailing Address - Fax:
Practice Address - Street 1:518 S CAMP MEADE RD STE 2
Practice Address - Street 2:
Practice Address - City:LINTHICUM HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:21090-2766
Practice Address - Country:US
Practice Address - Phone:410-702-8864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPERIAL MENTORING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty