Healthcare Provider Details

I. General information

NPI: 1538904685
Provider Name (Legal Business Name): GRAEME THISTLEWAITE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2024
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10630 LITTLE PATUXENT PKWY STE AND209A
COLUMBIA MD
21044-3264
US

IV. Provider business mailing address

10630 LITTLE PATUXENT PKWY STE AND209A
COLUMBIA MD
21044-3264
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-8066
  • Fax: 410-740-8068
Mailing address:
  • Phone:
  • Fax: 410-740-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: