Healthcare Provider Details

I. General information

NPI: 1902074404
Provider Name (Legal Business Name): STATE OF MARYLAND - UNIVERSITY OF MARYLAND COLLEGE PARK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LEFRAK HALL
COLLEGE PARK MD
20742-0001
US

IV. Provider business mailing address

110 LEFRAK HALL
COLLEGE PARK MD
20742-0001
US

V. Phone/Fax

Practice location:
  • Phone: 301-405-4218
  • Fax: 301-314-2023
Mailing address:
  • Phone: 301-405-4218
  • Fax: 301-314-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number00130
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number02036
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number00130
License Number StateMD

VIII. Authorized Official

Name: MS. RACHELLE BEASLEY
Title or Position: DIRECTOR OF ADMINISTRATIVE SERVICES
Credential:
Phone: 301-405-5401