Basic Information
| Provider Information | |||||||||
| NPI: | 1407200884 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 56 WEST FREDERICK STREET OPERATIONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GLADE VALLEY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 W FREDERICK ST | ||||||||
| Address2: | |||||||||
| City: | WALKERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217938254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018984300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 56 W FREDERICK ST | ||||||||
| Address2: | |||||||||
| City: | WALKERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217938254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018984300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2016 | ||||||||
| LastUpdateDate: | 08/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684752 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 10015 | MD | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | 10015 | MD | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 556222800 | 05 | MD | MEDICAID |