Healthcare Provider Details

I. General information

NPI: 1346040532
Provider Name (Legal Business Name): KATHERINE NICODEMUS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 SAMUEL MORSE DR STE 150
COLUMBIA MD
21046-3420
US

IV. Provider business mailing address

6213 FUSHSIMI CT
BURKE VA
22015-3451
US

V. Phone/Fax

Practice location:
  • Phone: 888-344-5977
  • Fax:
Mailing address:
  • Phone: 571-337-2326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: