MEDICARE: THE COMMUNITY RESOURCE CENTER,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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1619448008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE COMMUNITY RESOURCE CENTER,LLC.

Provider Business Mailing Address
First Line	:	4601 PARK HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-6331
Country	:	US
Telephone Number	:	443-473-6804
Fax Number	:

Provider Business Practice Location Address
First Line	:	4601 PARK HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21215-6331
Country	:	US
Telephone Number	:	443-473-6804
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DELORES KING
Credential	:	MADC. ADT.
Telephone Number	:	443-473-6804

Provider Enumeration Date	:	12/10/2018
Last Update Date	:	12/10/2018

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