Healthcare Provider Details

I. General information

NPI: 1316591985
Provider Name (Legal Business Name): RAISA ALIF MANEJWALA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 BAY RIDGE AVE STE 190
ANNAPOLIS MD
21403-2834
US

IV. Provider business mailing address

1819 BAY RIDGE AVE STE 190
ANNAPOLIS MD
21403-2834
US

V. Phone/Fax

Practice location:
  • Phone: 443-281-9430
  • Fax: 443-782-2446
Mailing address:
  • Phone: 443-281-9430
  • Fax: 443-782-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number06189
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: