Basic Information
| Provider Information | |||||||||
| NPI: | 1508811936 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYLAND TREATMENT CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MOUNTAIN MANOR TREATMENT CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 FREDERICK AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212293618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102331400 | ||||||||
| FaxNumber: | 4102335583 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 FREDERICK AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212293618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102331400 | ||||||||
| FaxNumber: | 4102335583 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/18/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GROVES | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4102331400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MED. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | MD | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0800X | MD | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | MD | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0804X | MD | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 251300000X | 3799 | MD | N | Agencies | Local Education Agency (LEA) | 261QM0801X | 14077 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X | 14077 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | 14077 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QR0405X | 903139 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 903143 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 3245S0500X | 903140 | MD | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 324500000X | 903140 | MD | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 090501100 | 05 | MD | MEDICAID | 203102700 | 05 | MD | MEDICAID | 510126302 | 05 | MD | MEDICAID | 774502800 | 05 | MO | MEDICAID | 039155700 | 05 | MD | MEDICAID | 391090301 | 05 | MD | MEDICAID |