MEDICARE: CENTRE PARK COUNSELING CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YP2500X	Professional Counselor
3	104100000X	Social Worker
4	1041C0700X	Clinical Social Worker
5	103T00000X	Psychologist

General Provider Information

NPI Number	:	1003040742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRE PARK COUNSELING CENTER LLC

Provider Business Mailing Address
First Line	:	10141 BELL INN LN
Second Line	:
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-5650
Country	:	US
Telephone Number	:	317-690-6013
Fax Number	:

Provider Business Practice Location Address
First Line	:	8808 CENTRE PARK DR
Second Line	:	SECOND FLOOR
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2126
Country	:	US
Telephone Number	:	317-690-6013
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JOSEPH P DELLINGER
Credential	:
Telephone Number	:	317-690-6013

Provider Enumeration Date	:	05/11/2009
Last Update Date	:	05/11/2009

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