Basic Information
Provider Information | |||||||||
NPI: | 1306176961 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RESOURCES FOR HUMAN DEVELOPMENT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVERY ROAD COMBINED CARE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14701 AVERY RD | ||||||||
Address2: |   | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208533605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3012798828 | ||||||||
FaxNumber: | 3012798910 | ||||||||
Practice Location | |||||||||
Address1: | 14701 AVERY RD | ||||||||
Address2: |   | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208533605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3012798828 | ||||||||
FaxNumber: | 3012798910 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/05/2010 | ||||||||
LastUpdateDate: | 01/05/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WINTON | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3012798828 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW-C | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 903558 | MD | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
ID Information
ID | Type | State | Issuer | Description | 413790600 | 05 | MD |   | MEDICAID |