Organization
MENTOR-MARYLAND
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. IVY SIMMONS PH.D (DIRECTOR OF OMHC)
(410) 455-4600
Entity
Organization
Contact information
Practice address
1540 CATON CENTER DRIVE, HALETHORPE, MD 21227
(410) 737-4200
Mailing address
5720 EXECUTIVE DRIVE, CATONSVILLE, MD 21228
(410) 455-4600
(410) 455-4659
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
MH-1757
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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