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General NPI Number Information
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NPI Number | 1750817912
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Entity Type | Organization
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Legal Business Name | MENTOR-MARYLAND
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Dates
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Enumeration Date | 05/10/2017
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Last Update Date | 05/10/2017
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Provider Practice Location Address
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Address Line | 620 WEST NAYLOR MILL ROAD SUITE A-F
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City | SALISBURY
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State | MD
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Zip | 21801
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Country | US
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Telephone | 410-548-5921
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Fax |
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Provider Business Mailing Address
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Address Line | 5720 EXECUTIVE DRIVE
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City | CATONSVILLE
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State | MD
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Zip | 21228
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Country | US
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Telephone | 410-455-4600
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Fax | 410-455-4659
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Authorized Official
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Title or Position | DIRECTOR, OMHC
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Name | DR. CAROL IVY SIMMONS
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Credential | PH.D., LCSW-C
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Telephone | 410-455-4600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | MH-1792
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License Number State | MD
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