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General NPI Number Information
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NPI Number | 1407030463
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Entity Type | Organization
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Legal Business Name | KEYSTONE RECOVERY, LLC
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Dates
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Enumeration Date | 12/26/2007
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Last Update Date | 12/26/2007
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Provider Practice Location Address
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Address Line | 29000 US HIGHWAY 98 SUITE A-203
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City | DAPHNE
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State | AL
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Zip | 36526-7272
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Country | US
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Telephone | 251-626-5797
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Fax |
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Provider Business Mailing Address
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Address Line | 29000 US HIGHWAY 98 SUITE A-203
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City | DAPHNE
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State | AL
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Zip | 36526-7272
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Country | US
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Telephone | 251-626-5797
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR/THERAPIST
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Name | MRS. MARY ASHLEY CASSITY SIMPSON
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Credential | M.A., A.L.C., M.L.A.
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Telephone | 251-626-5797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 150MLAP
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | C1058A
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License Number State | AL
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