Healthcare Provider Details

I. General information

NPI: 1518353382
Provider Name (Legal Business Name): GILLIAN MARY STAVRO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 GREENSPRING AVE STE 200
BALTIMORE MD
21209-4357
US

IV. Provider business mailing address

217 WHITMOOR TER
SILVER SPRING MD
20901-1522
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-7375
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number04623
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: