Healthcare Provider Details

I. General information

NPI: 1083035125
Provider Name (Legal Business Name): CAPITOL HILL SUPPORTIVE SERVICES PROGRAM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2052 W VIRGINIA AVE NE
WASHINGTON DC
20002-1832
US

IV. Provider business mailing address

2052 W VIRGINIA AVE NE
WASHINGTON DC
20002-1832
US

V. Phone/Fax

Practice location:
  • Phone: 202-543-4212
  • Fax: 202-543-0059
Mailing address:
  • Phone: 202-543-4212
  • Fax: 202-543-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number025928400
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number025928400
License Number StateDC

VIII. Authorized Official

Name: TONYA COPPIN
Title or Position: EXECUTIVE DIRECTOR
Credential: MS.ED;MS.SP,ED
Phone: 202-543-4212