Healthcare Provider Details

I. General information

NPI: 1740864412
Provider Name (Legal Business Name): CASEY DUBAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 01/02/2022
Certification Date: 01/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SAINT PAUL ST STE 409
BALTIMORE MD
21202-2102
US

IV. Provider business mailing address

10042 THE MENDING WALL
COLUMBIA MD
21044-1711
US

V. Phone/Fax

Practice location:
  • Phone: 443-449-5604
  • Fax:
Mailing address:
  • Phone: 410-718-8298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLGP9551
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: