Healthcare Provider Details

I. General information

NPI: 1821071176
Provider Name (Legal Business Name): AVERY HALFWAY HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14705 AVERY RD
ROCKVILLE MD
20853-3605
US

IV. Provider business mailing address

14705 AVERY RD
ROCKVILLE MD
20853-3605
US

V. Phone/Fax

Practice location:
  • Phone: 301-762-4651
  • Fax: 301-762-4836
Mailing address:
  • Phone: 301-762-4651
  • Fax: 301-762-4836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number9217
License Number StateMD

VIII. Authorized Official

Name: LORENE LAKE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 410-974-6829