Healthcare Provider Details

I. General information

NPI: 1477239895
Provider Name (Legal Business Name): MARY CHAMBERS CACII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 BELLEVUE ST SE
WASHINGTON DC
20032-6030
US

IV. Provider business mailing address

920 BELLEVUE ST SE
WASHINGTON DC
20032-6030
US

V. Phone/Fax

Practice location:
  • Phone: 202-562-4939
  • Fax:
Mailing address:
  • Phone: 202-562-4939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCACI1072
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: