Healthcare Provider Details

I. General information

NPI: 1730937756
Provider Name (Legal Business Name): ELIAS SAMUEL LORIA GARRO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1741 ASHLAND AVE
BALTIMORE MD
21205-1531
US

IV. Provider business mailing address

1741 ASHLAND AVE
BALTIMORE MD
21205-1531
US

V. Phone/Fax

Practice location:
  • Phone: 479-774-5663
  • Fax:
Mailing address:
  • Phone: 443-993-1870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number07486
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: