Provider Demographics
NPI:1548984404
Name:MAGELLAN PROVIDER SERVICES OF CA PC
Entity type:Organization
Organization Name:MAGELLAN PROVIDER SERVICES OF CA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-406-8632
Mailing Address - Street 1:8621 ROBERT FULTON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-2620
Mailing Address - Country:US
Mailing Address - Phone:833-605-0634
Mailing Address - Fax:
Practice Address - Street 1:8621 ROBERT FULTON DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2620
Practice Address - Country:US
Practice Address - Phone:833-605-0634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty