=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417936287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CCHD - SUBSTANCE ABUSE SRVCS - BARSTOW
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2006
-----------------------------------------------------
Last Update Date | 07/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 280 STAFFORD ROAD
-----------------------------------------------------
City | BARSTOW
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-535-3079
-----------------------------------------------------
Fax | 410-535-2220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1158
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-535-3079
-----------------------------------------------------
Fax | 410-535-2220
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BEHAVIORAL HEALTH DIRECTOR
-----------------------------------------------------
Name | MRS. DORIS J. MCDONALD
-----------------------------------------------------
Credential | MA, LCADC, LCDC
-----------------------------------------------------
Telephone | 410-535-3079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 12086
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------