Healthcare Provider Details

I. General information

NPI: 1477314011
Provider Name (Legal Business Name): INNERCITY COLLABORATIVE COMMUNITY DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 CALL PL SE
WASHINGTON DC
20019-6321
US

IV. Provider business mailing address

5219 CALL PL SE
WASHINGTON DC
20019-6321
US

V. Phone/Fax

Practice location:
  • Phone: 240-304-6822
  • Fax: 301-336-5164
Mailing address:
  • Phone: 240-304-6822
  • Fax: 301-336-5164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: REV JUDIE SHEPHERD-GORE
Title or Position: EXECUTIVE DIRECTOR
Credential: JD, MBA
Phone: 240-304-6822