MEDICARE: C. O. A. C. H. MENTAL HEALTH, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LC3757	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BH001372	OTHER	MD	MARYLAND DEPARTMENT OF HEALTH, BEHAVIORAL HEALTH ADMINISTRATION

General Provider Information

NPI Number	:	1265771646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C. O. A. C. H. MENTAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	5 SHAWAN RD STE 101C
Second Line	:
City	:	HUNT VALLEY
State	:	MD
Zip	:	21030-1373
Country	:	US
Telephone Number	:	443-982-0692
Fax Number	:	443-982-0610

Provider Business Practice Location Address
First Line	:	5 SHAWAN RD STE 101C
Second Line	:
City	:	HUNT VALLEY
State	:	MD
Zip	:	21030-1373
Country	:	US
Telephone Number	:	443-982-0692
Fax Number	:	443-982-0610

Authorized Official
Title or Position	:	OWNER
Name	:	DWAYNE GREEN
Credential	:	LCPC
Telephone Number	:	443-506-6313

Provider Enumeration Date	:	02/05/2013
Last Update Date	:	02/25/2019

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