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General NPI Number Information
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NPI Number | 1922663574
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Entity Type | Organization
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Legal Business Name | ICWC RECOVERY INC
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Dates
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Enumeration Date | 05/08/2019
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Last Update Date | 05/08/2019
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Provider Practice Location Address
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Address Line | 4413 PARK HEIGHTS AVE
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City | BALTIMORE
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State | MD
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Zip | 21215-6323
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Country | US
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Telephone | 443-708-3834
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Fax |
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Provider Business Mailing Address
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Address Line | 4413 PARK HEIGHTS AVE
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City | BALTIMORE
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State | MD
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Zip | 21215-6323
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Country | US
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Telephone | 443-708-3834
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | TYRICA CASON
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Credential |
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Telephone | 856-304-3911
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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