Healthcare Provider Details

I. General information

NPI: 1629656830
Provider Name (Legal Business Name): JANICE BLACKBURN MENTZER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11116 MEDICAL CAMPUS RD STE 2989
HAGERSTOWN MD
21742-6710
US

IV. Provider business mailing address

11116 MEDICAL CAMPUS RD STE 2989
HAGERSTOWN MD
21742-6710
US

V. Phone/Fax

Practice location:
  • Phone: 301-766-7600
  • Fax: 301-766-7702
Mailing address:
  • Phone: 301-766-7600
  • Fax: 301-766-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number08898
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: