Basic Information
| Provider Information | |||||||||
| NPI: | 1306432307 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY BEHAVIORAL HEALTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 426 DORCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216132446 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 COURSEVALL DR STE 107 | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216172806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442245264 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2020 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | GILBERT | ||||||||
| AuthorizedOfficialFirstName: | LACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8442245264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385H00000X | Y | Respite Care Facility | Respite Care |
ID Information
| ID | Type | State | Issuer | Description | 422612702 | 05 | MD | MEDICAID |