Healthcare Provider Details

I. General information

NPI: 1619168366
Provider Name (Legal Business Name): MIRIAM BEADLE, PH.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 CONNECTICUT AVE NW SUITE #136
WASHINGTON DC
20008-2509
US

IV. Provider business mailing address

PO BOX 638
COLUMBIA MD
21045-0638
US

V. Phone/Fax

Practice location:
  • Phone: 202-536-5602
  • Fax:
Mailing address:
  • Phone: 202-536-5602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1000047
License Number StateDC

VIII. Authorized Official

Name: MS. CARLA SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 202-536-5602