Provider Demographics
NPI:1659805828
Name:MID-ATLANTIC BUREAU OF RECOVERY AND SOBRIETY
Entity Type:Organization
Organization Name:MID-ATLANTIC BUREAU OF RECOVERY AND SOBRIETY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL
Authorized Official - Prefix:
Authorized Official - First Name:JUDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HITCHMON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:202-779-8655
Mailing Address - Street 1:3212 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-6239
Mailing Address - Country:US
Mailing Address - Phone:954-942-7407
Mailing Address - Fax:
Practice Address - Street 1:3212 SE 7TH ST
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-6239
Practice Address - Country:US
Practice Address - Phone:954-942-7407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-14
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW12345251B00000X, 261QH0100X, 3104A0630X, 311ZA0620X, 320600000X, 322D00000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593641757OtherNON MEDICARE