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General NPI Number Information
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NPI Number | 1366981672
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Entity Type | Organization
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Legal Business Name | FRESH START RECOVERY
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Dates
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Enumeration Date | 02/20/2017
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Last Update Date | 02/20/2017
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Provider Practice Location Address
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Address Line | 15886 GAITHER DR
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City | GAITHERSBURG
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State | MD
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Zip | 20877-1404
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Country | US
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Telephone | 954-234-2469
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Fax | 954-234-2469
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Provider Business Mailing Address
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Address Line | 15886 GAITHER DR
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City | GAITHERSBURG
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State | MD
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Zip | 20877-1404
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Country | US
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Telephone | 954-234-2469
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Fax | 954-234-2469
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CATHY PICILLO
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Credential |
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Telephone | 954-234-2469
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number | D0046457
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License Number State | MD
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