Healthcare Provider Details

I. General information

NPI: 1538953328
Provider Name (Legal Business Name): EVIDENCE SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 LAKE FOREST DR
UPPER MARLBORO MD
20774-8983
US

IV. Provider business mailing address

2410 SUSAN HODGES PL
UPPER MARLBORO MD
20774-8945
US

V. Phone/Fax

Practice location:
  • Phone: 240-716-4638
  • Fax:
Mailing address:
  • Phone: 240-716-4638
  • 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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. FRITZ EBULOH
Title or Position: CEO
Credential:
Phone: 240-716-4638