Healthcare Provider Details

I. General information

NPI: 1750517892
Provider Name (Legal Business Name): MARY ANN BRUCE LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 STANFORD BLVD
COLUMBIA MD
21045-5805
US

IV. Provider business mailing address

8930 STANFORD BLVD
COLUMBIA MD
21045-5805
US

V. Phone/Fax

Practice location:
  • Phone: 410-313-6281
  • Fax: 410-313-6212
Mailing address:
  • Phone: 410-313-6281
  • Fax: 410-313-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA382
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: