Healthcare Provider Details

I. General information

NPI: 1134289895
Provider Name (Legal Business Name): MICHELLE ANN KISER OWUSU LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 E ANTIETAM ST STE 101
HAGERSTOWN MD
21740-5736
US

IV. Provider business mailing address

322 E ANTIETAM ST STE 101
HAGERSTOWN MD
21740-5736
US

V. Phone/Fax

Practice location:
  • Phone: 17-332-4313
  • Fax:
Mailing address:
  • Phone: 17-332-4313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16865
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: