Healthcare Provider Details

I. General information

NPI: 1134471188
Provider Name (Legal Business Name): AUDREY PARKER-BALTHASER CAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 AIRPAX RD BLDG B STE 300
CAMBRIDGE MD
21613-6401
US

IV. Provider business mailing address

828 AIRPAX RD BLDG B STE 300
CAMBRIDGE MD
21613-6401
US

V. Phone/Fax

Practice location:
  • Phone: 410-228-3929
  • Fax: 410-228-3810
Mailing address:
  • Phone: 410-228-3929
  • Fax: 410-228-3810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAC0753
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: