Provider Demographics
NPI:1821559865
Name:PROVIDENCE HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:PROVIDENCE HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ADELAIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:ETSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-841-8907
Mailing Address - Street 1:220 I ST NE STE 110
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-4365
Mailing Address - Country:US
Mailing Address - Phone:202-486-1894
Mailing Address - Fax:
Practice Address - Street 1:220 I ST NE STE 110
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4365
Practice Address - Country:US
Practice Address - Phone:202-486-1894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-30
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC070220-430OtherDEPARTMENT OF BEHAVIORAL HEALTH