Healthcare Provider Details

I. General information

NPI: 1679482392
Provider Name (Legal Business Name): CHARLISA FELIESH ADDISON ADT TRAINEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHARLISA ADDISON

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 BUSINESS CENTER WAY STE 102
EDGEWOOD MD
21040-1504
US

IV. Provider business mailing address

1315 GOLD MEADOW WAY APT 101
EDGEWOOD MD
21040-1523
US

V. Phone/Fax

Practice location:
  • Phone: 667-777-1231
  • Fax:
Mailing address:
  • Phone: 667-777-1231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number4143
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: