Basic Information
| Provider Information | |||||||||
| NPI: | 1154939296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORSICA RIVER MENTAL HEALTH SERVICE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 BANJO LN | ||||||||
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| City: | CENTREVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216171002 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 403 HIGH ST | ||||||||
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| City: | CAMBRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216131804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432255780 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2020 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | ADKINS | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4107583050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
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.