Provider Demographics
NPI:1306095617
Name:CHRYSALLIS, INC.
Entity type:Organization
Organization Name:CHRYSALLIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ILENE
Authorized Official - Middle Name:TONDELAYO
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:301-853-6754
Mailing Address - Street 1:6495 NEW HAMPSHIRE AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-3245
Mailing Address - Country:US
Mailing Address - Phone:301-853-6754
Mailing Address - Fax:301-853-6756
Practice Address - Street 1:6495 NEW HAMPSHIRE AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-3245
Practice Address - Country:US
Practice Address - Phone:301-853-6754
Practice Address - Fax:301-853-6756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC039289400Medicaid