Provider Demographics
NPI:1801279393
Name:WISCONSIN AVE PSYCHIATRIC CENTER INC
Entity type:Organization
Organization Name:WISCONSIN AVE PSYCHIATRIC CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAUMGARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-885-5600
Mailing Address - Street 1:4228 WISCONSIN AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-2138
Mailing Address - Country:US
Mailing Address - Phone:202-885-5600
Mailing Address - Fax:202-885-5842
Practice Address - Street 1:4228 WISCONSIN AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-2138
Practice Address - Country:US
Practice Address - Phone:202-885-5600
Practice Address - Fax:202-885-5842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0011101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD448740100Medicaid
569223OtherMEDICARE
DC026392500Medicaid
MD074500600Medicaid
MD208290000Medicaid
DC026402100Medicaid
094004Medicare Oscar/Certification