MEDICARE: MUNDRAE DALLAS WHITE LCADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCA2225	MD

General Provider Information

NPI Number	:	1669832028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MUNDRAE DALLAS WHITE LCADC

Provider Business Mailing Address
First Line	:	3218 MAYFAIR RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-4561
Country	:	US
Telephone Number	:	410-725-8611
Fax Number	:

Provider Business Practice Location Address
First Line	:	3218 MAYFAIR RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-4561
Country	:	US
Telephone Number	:	410-725-8611
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/29/2016
Last Update Date	:	02/29/2016

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