=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871820258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CERTIFIED COUNSELING SERVICES OF CENTREVILLE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2009
-----------------------------------------------------
Last Update Date | 11/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 BANJO LN STE A
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21617-1054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-758-4456
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 23
-----------------------------------------------------
City | CHESTERTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21620-0023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | JOSEPH KEITH JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-758-4456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | LCA449
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------