Provider Demographics
NPI:1366981672
Name:FRESH START RECOVERY
Entity type:Organization
Organization Name:FRESH START RECOVERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-234-2469
Mailing Address - Street 1:15886 GAITHER DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1404
Mailing Address - Country:US
Mailing Address - Phone:954-234-2469
Mailing Address - Fax:954-234-2469
Practice Address - Street 1:15886 GAITHER DR
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1404
Practice Address - Country:US
Practice Address - Phone:954-234-2469
Practice Address - Fax:954-234-2469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046457103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD0046457OtherSTATE