Organization
ALLEGIANCE TO SELF RECOVERY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ANTWONE SHAW (CEO)
(502) 322-2065
Entity
Organization
Contact information
Practice address
3711 W BROADWAY, LOUISVILLE, KY 40211-2847
(502) 322-2065
Mailing address
9508 YELLOW PINE CT, LOUISVILLE, KY 40229-1642
(502) 322-2065
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
251B00000X
Case Management Agency
—
—
251S00000X
Community/Behavioral Health Agency
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
—
—
261QR0800X
Recovery Care Clinic/Center
—
—
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Enumeration date
11/11/2024
Last updated
12/10/2024
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