Basic Information
| Provider Information | |||||||||
| NPI: | 1316206295 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED CATHOLIC CHARITIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VILLA MARIA BEHAVIROAL HEALTH AT MILLER'S COURT OMHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1966 GREENSPRING DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TIMONIUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210934117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437983395 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2601 N HOWARD ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212184666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107274800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 09/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | CANOSA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4102524700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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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) |
ID Information
| ID | Type | State | Issuer | Description | 421155300 | 05 | MD | MEDICAID |