Healthcare Provider Details

I. General information

NPI: 1699103622
Provider Name (Legal Business Name): DCPS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5504 TROUT RUN RD
CLINTON MD
20735
US

IV. Provider business mailing address

5504 TROUT RUN RD
CLINTON MD
20735-1568
US

V. Phone/Fax

Practice location:
  • Phone: 202-673-7385
  • Fax:
Mailing address:
  • Phone: 202-673-7385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLG50078138
License Number StateDC

VIII. Authorized Official

Name: MRS. NINA MONIQUE HARRISON
Title or Position: SOCIAL WORKER
Credential: LGSW
Phone: 202-673-7385