Healthcare Provider Details

I. General information

NPI: 1124204854
Provider Name (Legal Business Name): MARYLAND INSTITUTE FOR INDIVIDUAL & FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7307 BALTIMORE AVE SUITE 208
COLLEGE PARK MD
20740-3231
US

IV. Provider business mailing address

7307 BALTIMORE AVE SUITE 208
COLLEGE PARK MD
20740-3231
US

V. Phone/Fax

Practice location:
  • Phone: 301-277-3250
  • Fax: 301-927-8052
Mailing address:
  • Phone: 301-277-3250
  • Fax: 301-927-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number01730
License Number StateMD

VIII. Authorized Official

Name: DR. DAVID P FAGO
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 301-277-3250