Healthcare Provider Details

I. General information

NPI: 1184456832
Provider Name (Legal Business Name): MARY'S HOUSE OF GREATER WASHINGTON, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12804 WATER FOWL WAY
UPPER MARLBORO MD
20774-7028
US

IV. Provider business mailing address

12804 WATER FOWL WAY
UPPER MARLBORO MD
20774-7028
US

V. Phone/Fax

Practice location:
  • Phone: 240-467-7561
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: IBRAHIM KUTEYI
Title or Position: DIRECTOR
Credential:
Phone: 240-467-7561