Provider Demographics
NPI:1396747358
Name:CHESAPEAKE CHURCH
Entity type:Organization
Organization Name:CHESAPEAKE CHURCH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNGARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:410-257-5200
Mailing Address - Street 1:6045 SOLOMONS ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-8876
Mailing Address - Country:US
Mailing Address - Phone:410-257-5200
Mailing Address - Fax:410-257-2442
Practice Address - Street 1:6045 SOLOMONS ISLAND RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTOWN
Practice Address - State:MD
Practice Address - Zip Code:20639-8876
Practice Address - Country:US
Practice Address - Phone:410-257-5200
Practice Address - Fax:410-257-2442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-02
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLP57OtherCAREFIRST BC/BS
MDF453OtherCAREFIRST BLUECHOICE