Healthcare Provider Details

I. General information

NPI: 1255376695
Provider Name (Legal Business Name): KAMIL SUDAN MADINA LCSW-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N CHARLES ST SUITE 200
BALTIMORE MD
21201-4102
US

IV. Provider business mailing address

2631 GUILFORD AVE
BALTIMORE MD
21218-4613
US

V. Phone/Fax

Practice location:
  • Phone: 410-576-9191
  • Fax: 410-576-9257
Mailing address:
  • Phone: 410-366-8653
  • Fax: 410-576-9257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09921
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: