Provider Demographics
NPI:1912752221
Name:SUPPORTIVE CONNECTIONS
Entity Type:Organization
Organization Name:SUPPORTIVE CONNECTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:VICKERIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-676-6189
Mailing Address - Street 1:13616 VINCENT WAY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-6021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13616 VINCENT WAY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-6021
Practice Address - Country:US
Practice Address - Phone:240-676-6189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities