MEDICARE: COUNSELING CENTER AT DULUTH 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1770234650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNSELING CENTER AT DULUTH LLC

Provider Business Mailing Address
First Line	:	PO BOX 27090
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07101-6790
Country	:	US
Telephone Number	:	470-704-5010
Fax Number	:	470-704-5101

Provider Business Practice Location Address
First Line	:	4191 PLEASANT HILL RD STE 100
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-1411
Country	:	US
Telephone Number	:	470-704-5010
Fax Number	:	470-704-5101

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JOSEPH CHELALES
Credential	:
Telephone Number	:	646-285-4035

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	01/12/2022

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