Provider Demographics
NPI:1841781242
Name:POWELL RECOVERY CENTER
Entity Type:Organization
Organization Name:POWELL RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FAYTHE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:410-276-1773
Mailing Address - Street 1:14 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-1712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 N LAKEWOOD AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-1112
Practice Address - Country:US
Practice Address - Phone:410-276-1773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility