Healthcare Provider Details

I. General information

NPI: 1417936287
Provider Name (Legal Business Name): CCHD - SUBSTANCE ABUSE SRVCS - BARSTOW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 STAFFORD ROAD
BARSTOW MD
20610
US

IV. Provider business mailing address

P.O. BOX 1158
PRINCE FREDERICK MD
20678
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-3079
  • Fax: 410-535-2220
Mailing address:
  • Phone: 410-535-3079
  • Fax: 410-535-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number12086
License Number StateMD

VIII. Authorized Official

Name: MRS. DORIS J. MCDONALD
Title or Position: BEHAVIORAL HEALTH DIRECTOR
Credential: MA, LCADC, LCDC
Phone: 410-535-3079