Healthcare Provider Details

I. General information

NPI: 1073422580
Provider Name (Legal Business Name): MYA JUSTINE MCGINNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E PRATT ST
BALTIMORE MD
21202
US

IV. Provider business mailing address

1257 HOLLERING HILL RD
CAMDEN DE
19934-3041
US

V. Phone/Fax

Practice location:
  • Phone: 302-222-0491
  • Fax:
Mailing address:
  • Phone: 302-222-0491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: