1710449772 NPI number — WOODLEY PARK CLINICAL SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710449772 NPI number — WOODLEY PARK CLINICAL SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODLEY PARK CLINICAL SERVICES, 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:
1710449772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2403 JUMPER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPPER MARLBORO
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20774-9037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-481-1892
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 CONNECTICUT AVE NW STE 410
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20008-2552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-481-1892
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
AISHA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CLINICAL DIRECTOR/THERAPIST
Authorized Official Telephone Number:
240-481-1892

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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