Healthcare Provider Details

I. General information

NPI: 1235821810
Provider Name (Legal Business Name): CHARMAINE WITHERSPOON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 CHARLES PLZ APT 2707
BALTIMORE MD
21201-3946
US

IV. Provider business mailing address

15 CHARLES PLZ APT 2707
BALTIMORE MD
21201-3946
US

V. Phone/Fax

Practice location:
  • Phone: 602-872-8569
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number31096
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLMSW19620
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number31096
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: