Basic Information
| Provider Information | |||||||||
| NPI: | 1063677425 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASSOCIATED CATHOLIC CHARITIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | VILLA MARIA OF ANNE ARUNDEL COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2300 DULANEY VALLEY RD STE B | ||||||||
| Address2: | |||||||||
| City: | TIMONIUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210932739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6676002249 | ||||||||
| FaxNumber: | 6676004068 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 BENFIELD BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211083004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6676002494 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2008 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REEVES | ||||||||
| AuthorizedOfficialFirstName: | GLORIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | A/R AND BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6676002249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2022 | ||||||||
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) |
ID Information
| ID | Type | State | Issuer | Description | 153800405 | 05 | MD | MEDICAID |