Healthcare Provider Details

I. General information

NPI: 1497258784
Provider Name (Legal Business Name): CULLMAN COUNTY TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 COMMERCE AVE
CULLMAN AL
35055-6150
US

IV. Provider business mailing address

PO BOX 2085
CULLMAN AL
35056-2085
US

V. Phone/Fax

Practice location:
  • Phone: 256-739-5595
  • Fax:
Mailing address:
  • Phone: 256-739-5595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number112206
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1195
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number1195
License Number StateAL
# 4
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number1195
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LESLIE HOLLAND
Title or Position: EXECUTIVE DIRECTOR/OWNER
Credential: BS
Phone: 256-739-5595