Basic Information
| Provider Information | |||||||||
| NPI: | 1912101064 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | METRO TREATMENT OF MARYLAND | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HAGERSTOWN TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 217 E ANTIETAM ST | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217405724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017140837 | ||||||||
| FaxNumber: | 3017142931 | ||||||||
| Practice Location | |||||||||
| Address1: | 217 E ANTIETAM ST | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217405724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017140837 | ||||||||
| FaxNumber: | 3017142931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WATTS | ||||||||
| AuthorizedOfficialFirstName: | MARTY | ||||||||
| AuthorizedOfficialMiddleName: | SUSAN | ||||||||
| AuthorizedOfficialTitleorPosition: | LPN | ||||||||
| AuthorizedOfficialTelephone: | 3017140837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NURSING | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 0 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.