Healthcare Provider Details

I. General information

NPI: 1073101614
Provider Name (Legal Business Name): ANDREW WON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N HOWARD ST STE 300
BALTIMORE MD
21218-5909
US

IV. Provider business mailing address

16 MONTROSE MANOR CT APT G
CATONSVILLE MD
21228-5044
US

V. Phone/Fax

Practice location:
  • Phone: 443-438-6742
  • Fax:
Mailing address:
  • Phone: 443-255-7021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLGP11075
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: