Healthcare Provider Details

I. General information

NPI: 1114491834
Provider Name (Legal Business Name): CC BEHAVIORAL HEALTH LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 W JOPPA RD STE 130
LUTHERVILLE MD
21093
US

IV. Provider business mailing address

2324 W JOPPA RD STE 130
LUTHERVILLE MD
21093-4615
US

V. Phone/Fax

Practice location:
  • Phone: 773-540-7274
  • Fax:
Mailing address:
  • Phone: 773-540-7274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. CORALIE CASTRO
Title or Position: PRESIDENT
Credential: PSY.D., LCPC
Phone: 773-540-7274