MEDICARE: INNERSOURCED SOLUTIONS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1407314420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNERSOURCED SOLUTIONS, INC.

Provider Business Mailing Address
First Line	:	11705 BERRY RD STE 104
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20603-5933
Country	:	US
Telephone Number	:	240-207-4513
Fax Number	:	240-846-6037

Provider Business Practice Location Address
First Line	:	11705 BERRY RD STE 104
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20603-5933
Country	:	US
Telephone Number	:	240-207-4513
Fax Number	:	240-846-6037

Authorized Official
Title or Position	:	CEO
Name	:	DR. MICHELLE DILLARD
Credential	:	DSW, LCSW-C
Telephone Number	:	240-207-4513

Provider Enumeration Date	:	03/08/2019
Last Update Date	:	04/10/2023

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