Provider Demographics
NPI:1922663574
Name:ICWC RECOVERY INC
Entity Type:Organization
Organization Name:ICWC RECOVERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TYRICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-304-3911
Mailing Address - Street 1:4413 PARK HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-6323
Mailing Address - Country:US
Mailing Address - Phone:443-708-3834
Mailing Address - Fax:
Practice Address - Street 1:4413 PARK HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-6323
Practice Address - Country:US
Practice Address - Phone:443-708-3834
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty