Healthcare Provider Details

I. General information

NPI: 1497314157
Provider Name (Legal Business Name): DEBERA MARIE REZNITSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 07/04/2022
Certification Date: 07/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 WALKER AVE STE 512
BALTIMORE MD
21208-4022
US

IV. Provider business mailing address

3414 GLEN AVE
BALTIMORE MD
21215-3912
US

V. Phone/Fax

Practice location:
  • Phone: 410-415-3515
  • Fax:
Mailing address:
  • Phone: 410-664-9371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number01026
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: