MEDICARE: EXECUTIVE ADDICTIVE DISEASE PROGRAMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	PRC948	DC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	PRC13871	DC

General Provider Information

NPI Number	:	1740517283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE ADDICTIVE DISEASE PROGRAMS

Provider Business Mailing Address
First Line	:	4335 WISCONSIN AVE NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20016-2148
Country	:	US
Telephone Number	:	202-362-2588
Fax Number	:	202-966-4214

Provider Business Practice Location Address
First Line	:	4335 WISCONSIN AVE NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20016-2148
Country	:	US
Telephone Number	:	202-362-2588
Fax Number	:	202-966-4214

Authorized Official
Title or Position	:	OFFICE MANAGER/FINANCIAL COORDINATO
Name	:	MS. AMANDA CARPENTER
Credential	:
Telephone Number	:	202-362-2588

Provider Enumeration Date	:	11/04/2009
Last Update Date	:	11/04/2009

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