Organization
MENTOR-MARYLAND
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. CAROL IVY SIMMONS PH.D., LCSW-C (DIRECTOR, OMHC)
(410) 455-4600
Entity
Organization
Contact information
Practice address
5970 FREDERICK CROSSING LANE, #202, FREDERICK, MD 21704
(301) 524-0977
Mailing address
5720 EXECUTIVE DRIVE, CATONSVILLE, MD 21228
(410) 455-4600
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
MH-2279
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
056668
—
MD
Enumeration date
05/10/2017
Last updated
05/10/2017
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