1356384630 NPI number — MARY K STUDHAM LCSW C

Table of content: MARY K STUDHAM LCSW C (NPI 1356384630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356384630 NPI number — MARY K STUDHAM LCSW C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STUDHAM
Provider First Name:
MARY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356384630
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5407 N CHARLES STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21210-2024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-433-8861
Provider Business Mailing Address Fax Number:
410-433-1249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
731 BENFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEVERNA PARK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-433-8861
Provider Business Practice Location Address Fax Number:
410-433-1249
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  12344 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 253608 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 62145601 . This is a "BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0017 . This is a "FED BC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 253608 . This is a "MANAGED HEALTH NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 237880 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".




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