Healthcare Provider Details

I. General information

NPI: 1932409729
Provider Name (Legal Business Name): MAVERICK ADDICTION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2010
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 S STATE ST SUITE 1
NORTH VERNON IN
47265-1800
US

IV. Provider business mailing address

PO BOX 951 35 S. STATE ST., SUITE 1
NORTH VERNON IN
47265-0951
US

V. Phone/Fax

Practice location:
  • Phone: 812-953-1181
  • Fax: 812-953-1158
Mailing address:
  • Phone: 812-953-1181
  • Fax: 812-953-1158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number86000039A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateIN

VIII. Authorized Official

Name: MRS. VICKIE J COX
Title or Position: CEO & ADDICTION COUNSELOR
Credential: L.A.C. NCAC II...
Phone: 812-953-1181