Organization
MARY T MARYLAND
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CONNIE WINBAUER (CONTROLLER)
(763) 862-5436
Entity
Organization
Contact information
Practice address
820 RITCHIE HWY STE 100, SEVERNA PARK, MD 21146-4111
(410) 544-6813
(410) 544-6818
Mailing address
1555 118TH LN NW, COON RAPIDS, MN 55448-7579
(763) 862-5436
(763) 754-0332
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
—
MD
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
—
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
580015300
—
MD
Enumeration date
09/25/2009
Last updated
09/25/2009
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