Provider Demographics
NPI:1316061856
Name:ACT IV
Entity type:Organization
Organization Name:ACT IV
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADULT SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-698-2525
Mailing Address - Street 1:10005 LAWRENCE POND CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3049
Mailing Address - Country:US
Mailing Address - Phone:301-362-1771
Mailing Address - Fax:
Practice Address - Street 1:10005 LAWRENCE POND CT
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3049
Practice Address - Country:US
Practice Address - Phone:301-362-1771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH423356201579251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management