Healthcare Provider Details

I. General information

NPI: 1730300021
Provider Name (Legal Business Name): MARYAM SHAFIAH SURALEIGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W FAYETTE ST THIRD FLOOR
BALTIMORE MD
21201-1543
US

IV. Provider business mailing address

PO BOX 64277
BALTIMORE MD
21264-4277
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-2207
  • Fax: 410-328-9233
Mailing address:
  • Phone: 410-328-7037
  • Fax: 410-328-3311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number073512
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: