Provider Demographics
NPI:1609924877
Name:COURAGE TO CHANGE OF SOUTHERN MARYLAND
Entity Type:Organization
Organization Name:COURAGE TO CHANGE OF SOUTHERN MARYLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMKE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCADC
Authorized Official - Phone:410-414-9050
Mailing Address - Street 1:96 ARMORY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4117
Mailing Address - Country:US
Mailing Address - Phone:410-414-9050
Mailing Address - Fax:410-414-9060
Practice Address - Street 1:96 ARMORY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4117
Practice Address - Country:US
Practice Address - Phone:410-414-9050
Practice Address - Fax:410-414-9060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA091101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDMD-10343401OtherSAMIS ID