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General NPI Number Information
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NPI Number | 1659316636
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Entity Type | Organization
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Legal Business Name | MENTOR MD
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Dates
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Enumeration Date | 06/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4501 FORBES BLVD SUITE 140
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City | LANHAM
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State | MD
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Zip | 20706-4326
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Country | US
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Telephone | 301-459-3057
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Fax | 301-731-3142
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Provider Business Mailing Address
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Address Line | 4501 FORBES BLVD SUITE 140
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City | LANHAM
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State | MD
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Zip | 20706-4326
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Country | US
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Telephone | 301-459-3057
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Fax | 301-731-3142
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Authorized Official
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Title or Position | STATE DIRECTOR
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Name | MR. EDWARD MATRICARDI
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Credential | LCSW - C
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Telephone | 443-543-2101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 2012
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License Number State | MD
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