Healthcare Provider Details

I. General information

NPI: 1578573317
Provider Name (Legal Business Name): ELISE DIAZ SMITH C.C.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 BARNES ST STE 102
BEL AIR MD
21014-3960
US

IV. Provider business mailing address

424 BARNES ST STE 102
BEL AIR MD
21014-3960
US

V. Phone/Fax

Practice location:
  • Phone: 410-838-4327
  • Fax: 410-376-8161
Mailing address:
  • Phone: 410-838-4327
  • Fax: 410-376-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number01078
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: