Provider Demographics
NPI:1265771646
Name:C. O. A. C. H. MENTAL HEALTH, LLC
Entity type:Organization
Organization Name:C. O. A. C. H. MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:443-506-6313
Mailing Address - Street 1:5 SHAWAN RD STE 101C
Mailing Address - Street 2:
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21030-1373
Mailing Address - Country:US
Mailing Address - Phone:443-982-0692
Mailing Address - Fax:443-982-0610
Practice Address - Street 1:5 SHAWAN RD STE 101C
Practice Address - Street 2:
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-1373
Practice Address - Country:US
Practice Address - Phone:443-982-0692
Practice Address - Fax:443-982-0610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3757101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDBH001372OtherMARYLAND DEPARTMENT OF HEALTH, BEHAVIORAL HEALTH ADMINISTRATION