Basic Information
Provider Information | |||||||||
NPI: | 1134338015 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROBERT A. PASCAL YOUTH AND FAMILY SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 180 | ||||||||
Address2: |   | ||||||||
City: | ODENTON | ||||||||
State: | MD | ||||||||
PostalCode: | 211130180 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109750067 | ||||||||
FaxNumber: | 4109750204 | ||||||||
Practice Location | |||||||||
Address1: | 1215 ANNAPOLIS RD STE 204 | ||||||||
Address2: |   | ||||||||
City: | ODENTON | ||||||||
State: | MD | ||||||||
PostalCode: | 211131351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109750067 | ||||||||
FaxNumber: | 4109750204 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2007 | ||||||||
LastUpdateDate: | 04/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAMB | ||||||||
AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DOA | ||||||||
AuthorizedOfficialTelephone: | 4109750067 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 07545 | MD | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 9316001-00 | 05 | MD |   | MEDICAID | LL38 | 01 | MD | BCBS GROUP NUMBER | OTHER |