Basic Information
| Provider Information | |||||||||
| NPI: | 1326416629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED CATHOLIC CHARITIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VILLA MARIA BEHAVIORAL HEALTH SERVICES-CHERRY HILL | ||||||||
| 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 | ||||||||
| FaxNumber: | 4105617752 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 CHERRY HILL RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212252012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105850598 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2015 | ||||||||
| LastUpdateDate: | 09/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | CANOSA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4106081303 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.