Healthcare Provider Details

I. General information

NPI: 1619338225
Provider Name (Legal Business Name): MT. WASHINGTON PEDIATRIC COMMUNITY HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 INDUSTRY LN UNIT 5A
FOREST HILL MD
21050-1741
US

IV. Provider business mailing address

1708 W ROGERS AVE ATTN: FINANCE
BALTIMORE MD
21209-4545
US

V. Phone/Fax

Practice location:
  • Phone: 410-367-2222
  • Fax:
Mailing address:
  • Phone: 410-578-5163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MARY MILLER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 410-578-5163