Provider Demographics
NPI:1932782836
Name:SH DETOX HOUSTON, LLC
Entity Type:Organization
Organization Name:SH DETOX HOUSTON, LLC
Other - Org Name:SERENITY HOUSE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-839-6928
Mailing Address - Street 1:10019 REISTERSTOWN RD FL 3
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3902
Mailing Address - Country:US
Mailing Address - Phone:443-839-6928
Mailing Address - Fax:443-269-0667
Practice Address - Street 1:1450 CAMPBELL RD STE 100&200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-4667
Practice Address - Country:US
Practice Address - Phone:832-240-3024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SERENITY HOUSE DETOX
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-29
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder