Provider Demographics
NPI:1770605321
Name:VITAL SOURCES, LLC
Entity type:Organization
Organization Name:VITAL SOURCES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROEMBKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PSYD
Authorized Official - Phone:301-620-8700
Mailing Address - Street 1:116 RECORD ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-5418
Mailing Address - Country:US
Mailing Address - Phone:301-620-8700
Mailing Address - Fax:301-620-8710
Practice Address - Street 1:116 RECORD ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-5418
Practice Address - Country:US
Practice Address - Phone:301-620-8700
Practice Address - Fax:301-620-8710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysisGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD049NMedicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #