Basic Information
| Provider Information | |||||||||
| NPI: | 1073802138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WORCESTER COUNTY HEALTH DEPARTMENT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CENTER 4 CLEAN START | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6040 PUBLIC LANDING RD | ||||||||
| Address2: | |||||||||
| City: | SNOW HILL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218632453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106321100 | ||||||||
| FaxNumber: | 4106322476 | ||||||||
| Practice Location | |||||||||
| Address1: | 926 SNOW HILL ROAD | ||||||||
| Address2: | COTTAGE 200, HOLLY CENTER, CENTER 4 CLEAN START | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107423460 | ||||||||
| FaxNumber: | 4107425810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2011 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARTON | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, ADMINISTRATIVE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4106321100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 905074 | MD | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 367831800 | 05 | MD | MEDICAID |