Healthcare Provider Details

I. General information

NPI: 1114366309
Provider Name (Legal Business Name): STEPHEN COLYER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6355 WOODSIDE CT
COLUMBIA MD
21046-1071
US

IV. Provider business mailing address

6355 WOODSIDE CT
COLUMBIA MD
21046-1071
US

V. Phone/Fax

Practice location:
  • Phone: 410-381-7171
  • Fax: 410-381-4480
Mailing address:
  • Phone: 410-381-7171
  • Fax: 410-381-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number02695
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: