Healthcare Provider Details

I. General information

NPI: 1184449167
Provider Name (Legal Business Name): GREGORY WIATROWSKI MA CAS NCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N PAYSON ST
BALTIMORE MD
21217-1121
US

IV. Provider business mailing address

1600 N PAYSON ST
BALTIMORE MD
21217-1121
US

V. Phone/Fax

Practice location:
  • Phone: 410-396-0776
  • Fax:
Mailing address:
  • Phone: 410-396-0776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberCER-65929B1S7P9
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: