Healthcare Provider Details

I. General information

NPI: 1629493051
Provider Name (Legal Business Name): UNIVERSITY PSYCHOLOGICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 02/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W 25TH ST
BALTIMORE MD
21218-5003
US

IV. Provider business mailing address

6201 GREENBELT RD SUITE U-18
BERWYN HEIGHTS MD
20740-2354
US

V. Phone/Fax

Practice location:
  • Phone: 410-366-1717
  • Fax: 410-889-4167
Mailing address:
  • Phone: 410-576-9191
  • Fax: 410-576-9257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. CRYSTAL G SLAGLE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 410-576-9191