Healthcare Provider Details

I. General information

NPI: 1508008475
Provider Name (Legal Business Name): MATTHEW YEAZEL LCSW-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 03/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 BELLERIVE RD UNIT 5B
ANNAPOLIS MD
21409-4602
US

IV. Provider business mailing address

580 BELLERIVE RD UNIT 5B
ANNAPOLIS MD
21409-4602
US

V. Phone/Fax

Practice location:
  • Phone: 410-757-0846
  • Fax: 410-757-0846
Mailing address:
  • Phone: 410-757-0846
  • Fax: 410-757-0846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10058
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: