Healthcare Provider Details

I. General information

NPI: 1669932562
Provider Name (Legal Business Name): DAMASCUS HOUSE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 LARGO RD
UPPER MARLBORO MD
20772-7837
US

IV. Provider business mailing address

4405 LARGO RD
UPPER MARLBORO MD
20772-7837
US

V. Phone/Fax

Practice location:
  • Phone: 240-338-2534
  • Fax:
Mailing address:
  • Phone: 240-338-2534
  • 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 Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. KEVIN WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, LGPC
Phone: 240-338-2534