Healthcare Provider Details

I. General information

NPI: 1619054152
Provider Name (Legal Business Name): WILLIE J MYRICK KT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 LOCH RAVEN BLVD
BALTIMORE MD
21218-2108
US

IV. Provider business mailing address

1401 KITMORE RD
BALTIMORE MD
21239-3410
US

V. Phone/Fax

Practice location:
  • Phone: 410-605-7631
  • Fax:
Mailing address:
  • Phone: 410-433-4659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: