Basic Information
| Provider Information | |||||||||
| NPI: | 1821253188 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASSOCIATED CATHOLIC CHARITIES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VILLA MARIA OF WASHINGTON COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 DULANEY VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | TIMONIUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210932739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6676002249 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 324 E ANTIETAM ST STE 307A | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017335858 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2008 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REEVES | ||||||||
| AuthorizedOfficialFirstName: | GLORIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | A/R AND BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6676002249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/02/2020 | ||||||||
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 | 110171415 | 05 | MD | MEDICAID |