Provider Demographics
NPI:1104352368
Name:MENTOR-MARYLAND
Entity type:Organization
Organization Name:MENTOR-MARYLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, OMHC
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:IVY
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW-C
Authorized Official - Phone:410-455-4600
Mailing Address - Street 1:5720 EXECUTIVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228
Mailing Address - Country:US
Mailing Address - Phone:410-455-4600
Mailing Address - Fax:
Practice Address - Street 1:5970 FREDERICK CROSSING LANE
Practice Address - Street 2:#202
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704
Practice Address - Country:US
Practice Address - Phone:301-524-0977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMH-2279251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD056668Medicaid