MEDICARE: POWELL RECOVERY CENTER

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	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1376022905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POWELL RECOVERY CENTER

Provider Business Mailing Address
First Line	:	14 S BROADWAY
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21231-1712
Country	:	US
Telephone Number	:	410-276-1773
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 N FULTON AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21217-1505
Country	:	US
Telephone Number	:	410-276-1773
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT BILLING
Name	:	FAYTHE JOHNSON
Credential	:	LCSW-C
Telephone Number	:	410-276-1773

Provider Enumeration Date	:	08/14/2018
Last Update Date	:	08/14/2018

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Directions to “POWELL RECOVERY CENTER ” Practice Location

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