1609109131 NPI number — THE METAMORPHORSIS INSTITUTE, LLC

Table of content: (NPI 1609109131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609109131 NPI number — THE METAMORPHORSIS INSTITUTE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE METAMORPHORSIS INSTITUTE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1609109131
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7131 LIBERTY RD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21207-4575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-436-3003
Provider Business Mailing Address Fax Number:
443-436-3002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7131 LIBERTY RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21207-4575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-436-3003
Provider Business Practice Location Address Fax Number:
443-436-3002
Provider Enumeration Date:
09/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR-ENNIS
Authorized Official First Name:
MARY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PSYCHOLOGIST/MEMBER
Authorized Official Telephone Number:
443-444-5798

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  03567 , 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: 251502400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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