Healthcare Provider Details

I. General information

NPI: 1043466147
Provider Name (Legal Business Name): WHITE MARSH PSYCHIATRIC ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 09/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5024 CAMPBELL BLVD SUITE H
BALTIMORE MD
21236-5974
US

IV. Provider business mailing address

5024 CAMPBELL BLVD SUITE H
BALTIMORE MD
21236-5974
US

V. Phone/Fax

Practice location:
  • Phone: 410-931-6694
  • Fax:
Mailing address:
  • Phone: 410-931-6694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANNE C DENTON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 410-931-9280