Healthcare Provider Details

I. General information

NPI: 1407424013
Provider Name (Legal Business Name): EDITH BIGELOW TALEB CSC-AD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 WISE AVE
DUNDALK MD
21222
US

IV. Provider business mailing address

10996 4 SEASONS PL
CROWN POINT IN
46307
US

V. Phone/Fax

Practice location:
  • Phone: 888-339-7339
  • Fax:
Mailing address:
  • Phone: 888-339-7339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSC2441
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: