Healthcare Provider Details

I. General information

NPI: 1659805828
Provider Name (Legal Business Name): MID-ATLANTIC BUREAU OF RECOVERY AND SOBRIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3212 SE 7TH ST
POMPANO BEACH FL
33062-6239
US

IV. Provider business mailing address

3212 SE 7TH ST
POMPANO BEACH FL
33062-6239
US

V. Phone/Fax

Practice location:
  • Phone: 954-942-7407
  • Fax:
Mailing address:
  • Phone: 954-942-7407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberSW12345
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberSW12345
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberSW12345
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberSW12345
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License NumberSW12345
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberSW12345
License Number StateFL
# 7
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberSW12345
License Number StateFL

VIII. Authorized Official

Name: JUDINE HITCHMON
Title or Position: DIRECTOR OF CLINICAL
Credential: LCSW
Phone: 202-779-8655