Provider Demographics
NPI:1477314011
Name:INNERCITY COLLABORATIVE COMMUNITY DEVELOPMENT CORPORATION
Entity Type:Organization
Organization Name:INNERCITY COLLABORATIVE COMMUNITY DEVELOPMENT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REV JUDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPHERD-GORE
Authorized Official - Suffix:
Authorized Official - Credentials:JD, MBA
Authorized Official - Phone:240-304-6822
Mailing Address - Street 1:5219 CALL PL SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-6321
Mailing Address - Country:US
Mailing Address - Phone:240-304-6822
Mailing Address - Fax:301-336-5164
Practice Address - Street 1:5219 CALL PL SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-6321
Practice Address - Country:US
Practice Address - Phone:240-304-6822
Practice Address - Fax:301-336-5164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty