Healthcare Provider Details

I. General information

NPI: 1750106720
Provider Name (Legal Business Name): JANINE DIMITRIOU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 S EAST ST
FREDERICK MD
21701-5918
US

IV. Provider business mailing address

2402 GRAYSTONE LN
FREDERICK MD
21702-9426
US

V. Phone/Fax

Practice location:
  • Phone: 207-203-3277
  • Fax:
Mailing address:
  • Phone: 240-529-4689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: