Healthcare Provider Details

I. General information

NPI: 1497006589
Provider Name (Legal Business Name): TANYA Y PRINCE MHS, CAC-AD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 N CHARLES ST
BALTIMORE MD
21218-5778
US

IV. Provider business mailing address

5620 WESLEY AVE
BALTIMORE MD
21207-6827
US

V. Phone/Fax

Practice location:
  • Phone: 443-573-8673
  • Fax: 410-243-8175
Mailing address:
  • Phone: 443-760-2973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC1790
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: