Healthcare Provider Details

I. General information

NPI: 1780253708
Provider Name (Legal Business Name): NARDOS ZELLEKE BELLETE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9810 PATUXENT WOODS DR
COLUMBIA MD
21046-1595
US

IV. Provider business mailing address

1741 ASHLAND AVE
BALTIMORE MD
21205-1531
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-4360
  • Fax:
Mailing address:
  • Phone: 443-923-1870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number06911
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: