Healthcare Provider Details

I. General information

NPI: 1265918288
Provider Name (Legal Business Name): ST. JOHN'S COMMUNITY SERVICES MARYLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 MERGANSER CT
UPPER MARLBORO MD
20774-7021
US

IV. Provider business mailing address

2201 WISCONSIN AVE NW
WASHINGTON DC
20007-4105
US

V. Phone/Fax

Practice location:
  • Phone: 301-218-0915
  • Fax:
Mailing address:
  • Phone: 202-237-6391
  • Fax: 202-237-6352

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: MR. RICHARD C. BENNETT
Title or Position: CHIEF STRATEGIC INITIATIVES OFFICER
Credential:
Phone: 607-592-2842