MEDICARE: WOODBOURNE CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	30-073	MD
2	163WS0200X	School Registered Nurse
3	235Z00000X	Speech-Language Pathologist
4	1041S0200X	School Social Worker

General Provider Information

NPI Number	:	1659829398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODBOURNE CENTER

Provider Business Mailing Address
First Line	:	1301 WOODBOURNE AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21239-3316
Country	:	US
Telephone Number	:	410-433-1000
Fax Number	:	410-433-1459

Provider Business Practice Location Address
First Line	:	1301 WOODBOURNE AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21239-3316
Country	:	US
Telephone Number	:	410-433-1000
Fax Number	:	410-433-1459

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. ANTHONY WILSON
Credential	:
Telephone Number	:	410-433-1000

Provider Enumeration Date	:	09/12/2016
Last Update Date	:	09/12/2016

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Directions to “WOODBOURNE CENTER ” Practice Location

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