Healthcare Provider Details

I. General information

NPI: 1972013555
Provider Name (Legal Business Name): ALICIA ROSE PENN LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. ALICIA ROSE FRAGER

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10632 LITTLE PATUXENT PKWY STE 327
COLUMBIA MD
21044-6283
US

IV. Provider business mailing address

10632 LITTLE PATUXENT PKWY STE 327
COLUMBIA MD
21044-6283
US

V. Phone/Fax

Practice location:
  • Phone: 443-864-5647
  • Fax: 443-276-0905
Mailing address:
  • Phone: 443-864-5647
  • Fax: 443-276-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15018
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: