1760783187 NPI number — MRS. DEETTA M ROBERSON CARTER LCSWC

Table of content: MRS. DEETTA M ROBERSON CARTER LCSWC (NPI 1760783187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760783187 NPI number — MRS. DEETTA M ROBERSON CARTER LCSWC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERSON CARTER
Provider First Name:
DEETTA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSWC
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:
1760783187
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 WARREN ROAD
Provider Second Line Business Mailing Address:
SUITE 25A
Provider Business Mailing Address City Name:
PIKESVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-701-0770
Provider Business Mailing Address Fax Number:
443-279-2916

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 WARREN ROAD
Provider Second Line Business Practice Location Address:
SUITE 25A
Provider Business Practice Location Address City Name:
PIKESVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-701-0770
Provider Business Practice Location Address Fax Number:
443-279-2916
Provider Enumeration Date:
11/17/2010

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: 104100000X , with the licence number:  G12345 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 17501 , 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: 220218200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: AJ47 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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