Basic Information
Provider Information | |||||||||
NPI: | 1023339595 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASSOCIATED CATHOLIC CHARITIES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VILLA MARIA OF CAROLL COUNTY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1966 GREENSPRING DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | TIMONIUM | ||||||||
State: | MD | ||||||||
PostalCode: | 210934117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4437983395 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 255 CLIFTON BLVD | ||||||||
Address2: | SUITE 302 | ||||||||
City: | WESTMINSTER | ||||||||
State: | MD | ||||||||
PostalCode: | 211574690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108482037 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2010 | ||||||||
LastUpdateDate: | 06/18/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CANOSA | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR; DEPARTMENT OF COMMUNITY R | ||||||||
AuthorizedOfficialTelephone: | 4102524700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | P.H.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.