Provider Demographics
NPI:1932693611
Name:AWAY OF CHANGE COUNSELING SERVICE, LLC
Entity Type:Organization
Organization Name:AWAY OF CHANGE COUNSELING SERVICE, LLC
Other - Org Name:AWAY OF CHANGE COUNSELING SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER AND CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, MS, LCADC
Authorized Official - Phone:443-405-3193
Mailing Address - Street 1:5310 OLD COURT RD STE 304
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-6202
Mailing Address - Country:US
Mailing Address - Phone:443-405-3193
Mailing Address - Fax:443-272-7572
Practice Address - Street 1:6609 REISTERSTOWN RD STE 206
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-2315
Practice Address - Country:US
Practice Address - Phone:443-405-3193
Practice Address - Fax:443-272-7572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA2042101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty