Basic Information
| Provider Information | |||||||||
| NPI: | 1275614968 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANN RTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 N CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109383000 | ||||||||
| FaxNumber: | 4109383159 | ||||||||
| Practice Location | |||||||||
| Address1: | 6501 N CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109383000 | ||||||||
| FaxNumber: | 4109383159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 12/02/2016 | ||||||||
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| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, CORPORATE BUSINESS DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 4109383159 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | MD | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 754612200 | 05 | MD | MEDICAID |