Basic Information
| Provider Information | |||||||||
| NPI: | 1922244615 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYLAND TREATMENT CENTERS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAFE PASSAGES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 CHEVERLY AVE | ||||||||
| Address2: | 3RD AND 4TH FLOOR | ||||||||
| City: | CHEVERLY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207853125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017725174 | ||||||||
| FaxNumber: | 3017725647 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 CHEVERLY AVE | ||||||||
| Address2: | 3RD AND 4TH FLOOR | ||||||||
| City: | CHEVERLY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207853125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017725174 | ||||||||
| FaxNumber: | 3017725647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2008 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WESTWOOD | ||||||||
| AuthorizedOfficialFirstName: | MEGHAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE DIRECTOR OF MENTAL HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 3017625613 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW-C | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | 4091/22177 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | 4091/22177 | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | 4091/22177 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 090501101 | 05 | MD | MEDICAID | 4091/22177 | 01 | MD | STATE CERTIFICATE AS OUTPATIENT MENTAL HEALTH CLINIC | OTHER |