Healthcare Provider Details

I. General information

NPI: 1134758527
Provider Name (Legal Business Name): MECHELLE SUEZETTE NORRIS MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LOYOLA UNIVERSITY MARYLAND ATHLETICS 4501 N CHARLES ST.
BALTIMORE MD
21210
US

IV. Provider business mailing address

5423 QUEST CT
DALE CITY VA
22193
US

V. Phone/Fax

Practice location:
  • Phone: 410-617-5276
  • Fax: 410-617-5709
Mailing address:
  • Phone: 703-980-5117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA0001034
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: