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General NPI Number Information
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NPI Number | 1609924877
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Entity Type | Organization
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Legal Business Name | COURAGE TO CHANGE OF SOUTHERN MARYLAND
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Dates
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Enumeration Date | 01/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 96 ARMORY RD SUITE 102
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678-4117
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Country | US
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Telephone | 410-414-9050
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Fax | 410-414-9060
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Provider Business Mailing Address
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Address Line | 96 ARMORY RD SUITE 102
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678-4117
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Country | US
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Telephone | 410-414-9050
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Fax | 410-414-9060
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MS. MARJORIE HUMKE
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Credential | M.A., L.C.A.D.C.
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Telephone | 410-414-9050
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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 | LCA091
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License Number State | MD
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