MEDICARE: PROVIDENCE HOUSE INC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1710614870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HOUSE INC

Provider Business Mailing Address
First Line	:	4802 DEANWOOD DR
Second Line	:
City	:	CAPITOL HEIGHTS
State	:	MD
Zip	:	20743-1129
Country	:	US
Telephone Number	:	973-444-1983
Fax Number	:	443-584-4022

Provider Business Practice Location Address
First Line	:	4802 DEANWOOD DR
Second Line	:
City	:	CAPITOL HEIGHTS
State	:	MD
Zip	:	20743-1129
Country	:	US
Telephone Number	:	973-444-1983
Fax Number	:	443-584-4022

Authorized Official
Title or Position	:	CEO
Name	:	ANTHONY JEROME ANDERSON
Credential	:	PHD
Telephone Number	:	973-444-1983

Provider Enumeration Date	:	08/08/2022
Last Update Date	:	08/08/2022

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