Provider Demographics
NPI:1518396100
Name:WASHINGTON ADVENTIST UNIVERSITY COMMUNITY COUNSELING CENTER
Entity Type:Organization
Organization Name:WASHINGTON ADVENTIST UNIVERSITY COMMUNITY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:UPSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:LCADC, ABD
Authorized Official - Phone:301-576-0131
Mailing Address - Street 1:7600 FLOWER AVE
Mailing Address - Street 2:SUITE 441-PSYCHOLOGY DEPARTMENT
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-7744
Mailing Address - Country:US
Mailing Address - Phone:301-576-0131
Mailing Address - Fax:301-891-4054
Practice Address - Street 1:7600 FLOWER AVE
Practice Address - Street 2:SUITE 441-PSYCHOLOGY DEPARTMENT
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-7744
Practice Address - Country:US
Practice Address - Phone:301-576-0131
Practice Address - Fax:301-891-4054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA393101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SAMIS100033OtherOHCQ