Provider Demographics
NPI:1861968489
Name:COLLABORATIVE CONCEPTS OF MARYLAND
Entity type:Organization
Organization Name:COLLABORATIVE CONCEPTS OF MARYLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CERTIFIED SOCIAL WORKER-CL
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NEWTON-GUEST
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:301-318-1148
Mailing Address - Street 1:1400 MERCANTILE LANE, SUITE 208
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774
Mailing Address - Country:US
Mailing Address - Phone:301-318-1148
Mailing Address - Fax:
Practice Address - Street 1:1400 MERCANTILE LANE, SUITE 208
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774
Practice Address - Country:US
Practice Address - Phone:301-318-1148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD062835200Medicaid
MD512512000Medicaid