Healthcare Provider Details

I. General information

NPI: 1659739720
Provider Name (Legal Business Name): SAN MAR CHILDREN'S HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8504 MAPLEVILLE ROAD
BOONSBORO MD
21713
US

IV. Provider business mailing address

8504 MAPLEVILLE ROAD
BOONSBORO MD
21713
US

V. Phone/Fax

Practice location:
  • Phone: 301-733-9067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: JERICA MARIA WASHINGTON
Title or Position: DEPUTY EXECUTIVE DIRECTOR
Credential:
Phone: 301-733-9067