=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407088339
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN RIDGE BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2009
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1395 PICCARD DR STE 320
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-4349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-683-6202
-----------------------------------------------------
Fax | 240-683-6203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1395 PICCARD DR STE 320
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20850-4349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-683-6202
-----------------------------------------------------
Fax | 240-683-6203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMINA YOUSUFI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 240-683-6202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | D0056459
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------