Healthcare Provider Details

I. General information

NPI: 1093039182
Provider Name (Legal Business Name): FAMILY SERVICE FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 DELAWARE ROAD
FREDERICK MD
21701-4618
US

IV. Provider business mailing address

5301 76TH AVE
LANDOVER HILLS MD
20784-1703
US

V. Phone/Fax

Practice location:
  • Phone: 301-378-0261
  • Fax: 301-378-0267
Mailing address:
  • Phone: 301-459-2121
  • Fax: 301-918-9757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number4163
License Number StateMD

VIII. Authorized Official

Name: DAPHNE SMITH
Title or Position: BILLING MANAGER
Credential:
Phone: 301-459-2121