Healthcare Provider Details

I. General information

NPI: 1073872842
Provider Name (Legal Business Name): NEW LIFE ADDICTION COUNSELING SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2528 MOUNTAIN RD SUITE 204
PASADENA MD
21122-7203
US

IV. Provider business mailing address

2528 MOUNTAIN RD SUITE 204
PASADENA MD
21122-7203
US

V. Phone/Fax

Practice location:
  • Phone: 410-255-4475
  • Fax: 410-255-6277
Mailing address:
  • Phone: 410-255-4475
  • Fax: 410-255-6277

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. BEVERLY ANN ERVIN
Title or Position: DIRECTOR
Credential:
Phone: 410-255-4475