Healthcare Provider Details

I. General information

NPI: 1962411710
Provider Name (Legal Business Name): MALIKA DASHAWNE CLOSSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALIKA DASHAWNE OWENS

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W FAYETTE ST
BALTIMORE MD
21201-1543
US

IV. Provider business mailing address

PO BOX 64277
BALTIMORE MD
21264-4277
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-2293
  • Fax: 410-328-5895
Mailing address:
  • Phone: 410-328-7037
  • Fax: 410-328-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: