Provider Demographics
NPI:1902175128
Name:ADOLESCENT AND FAMILY SERVICES/ADDICTIONS
Entity Type:Organization
Organization Name:ADOLESCENT AND FAMILY SERVICES/ADDICTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY HEALTH OFFICER/OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURESKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-222-7377
Mailing Address - Street 1:122 LANGLEY RD N
Mailing Address - Street 2:STE A
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-6531
Mailing Address - Country:US
Mailing Address - Phone:410-222-6725
Mailing Address - Fax:410-222-6888
Practice Address - Street 1:3 HARRY S TRUMAN PKWY
Practice Address - Street 2:HD#19
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7031
Practice Address - Country:US
Practice Address - Phone:410-222-7135
Practice Address - Fax:410-222-4173
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANNE ARUNDEL COUNTY DEPT. OF HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-16
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD904875261Q00000X
MD261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD702191700Medicaid
MD702511401Medicaid