1528171154 NPI number — PROF. SUSAN MARIE VEDRAL LCSW-C

Table of content: PROF. SUSAN MARIE VEDRAL LCSW-C (NPI 1528171154)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528171154 NPI number — PROF. SUSAN MARIE VEDRAL LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VEDRAL
Provider First Name:
SUSAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
PROF.
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:
FABIAN
Provider Other First Name:
SUSAN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
PROF.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528171154
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8106 EDWILL AVE
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:
21237-1618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-825-2281
Provider Business Mailing Address Fax Number:
410-825-0757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1407 YORK RD
Provider Second Line Business Practice Location Address:
SUITE309
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-6097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-825-2281
Provider Business Practice Location Address Fax Number:
410-825-0757
Provider Enumeration Date:
08/17/2006

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:  10595 , 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: T080-0024 . This is a "BLUECHOICE MEMBER NUMBER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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