Provider Demographics
NPI:1659261378
Name:ISU COTTAGE LLC
Entity type:Organization
Organization Name:ISU COTTAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANYONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-643-1517
Mailing Address - Street 1:10390 SWIFT STREAM PL APT 305
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4867
Mailing Address - Country:US
Mailing Address - Phone:240-643-1517
Mailing Address - Fax:
Practice Address - Street 1:9335 ROUTE 29 APT 212
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-1828
Practice Address - Country:US
Practice Address - Phone:240-643-1517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-04
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities