Provider Demographics
NPI:1063643880
Name:DEPARTMENT OF YOUTH REHABILITATION SERVICES
Entity type:Organization
Organization Name:DEPARTMENT OF YOUTH REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF HEALTH SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:202-576-8139
Mailing Address - Street 1:1000 MOUNT OLIVET RD NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-2210
Mailing Address - Country:US
Mailing Address - Phone:202-576-8405
Mailing Address - Fax:202-576-8457
Practice Address - Street 1:1000 MOUNT OLIVET RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-2210
Practice Address - Country:US
Practice Address - Phone:202-576-8405
Practice Address - Fax:202-576-8457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC261QP2400X261QP2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health