Healthcare Provider Details

I. General information

NPI: 1851848972
Provider Name (Legal Business Name): CARRIE MARIE SOICIAL SERVICE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 BROADWAY SUITE N107
GARY IN
46402-2414
US

IV. Provider business mailing address

839 BROADWAY SUITE N107
GARY IN
46402-2414
US

V. Phone/Fax

Practice location:
  • Phone: 312-468-5336
  • Fax:
Mailing address:
  • Phone: 312-468-5336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. DARCELMARIE SMITH
Title or Position: CEO
Credential: M.A
Phone: 312-468-5336