Healthcare Provider Details

I. General information

NPI: 1609392547
Provider Name (Legal Business Name): UNIVERSITY PSYCHOLOGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E PATRICK ST
FREDERICK MD
21701-5729
US

IV. Provider business mailing address

6201 GREENBELT RD STE U18
BERWYN HEIGHTS MD
20740-2361
US

V. Phone/Fax

Practice location:
  • Phone: 410-576-9191
  • Fax:
Mailing address:
  • Phone: 301-345-1919
  • Fax: 301-345-5779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. CLARK J HUDAK JR.
Title or Position: PRESEIDENT/CEO
Credential: PH.D.
Phone: 410-576-9191