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General NPI Number Information
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NPI Number | 1932409729
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Entity Type | Organization
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Legal Business Name | MAVERICK ADDICTION SERVICES, LLC
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Dates
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Enumeration Date | 10/26/2010
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Last Update Date | 10/26/2010
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Provider Practice Location Address
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Address Line | 35 S STATE ST SUITE 1
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City | NORTH VERNON
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State | IN
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Zip | 47265-1800
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Country | US
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Telephone | 812-953-1181
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Fax | 812-953-1158
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Provider Business Mailing Address
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Address Line | PO BOX 951 35 S. STATE ST., SUITE 1
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City | NORTH VERNON
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State | IN
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Zip | 47265-0951
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Country | US
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Telephone | 812-953-1181
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Fax | 812-953-1158
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Authorized Official
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Title or Position | CEO & ADDICTION COUNSELOR
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Name | MRS. VICKIE J COX
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Credential | L.A.C. NCAC II...
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Telephone | 812-953-1181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 86000039A
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License Number State | IN
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