Healthcare Provider Details

I. General information

NPI: 1891001996
Provider Name (Legal Business Name): LA PLATA PEDIATRICS & FAMILY HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CENTENNIAL ST SUITE B
LA PLATA MD
20646-5984
US

IV. Provider business mailing address

103 CENTENNIAL ST STE B
LA PLATA MD
20646-5985
US

V. Phone/Fax

Practice location:
  • Phone: 301-643-8127
  • Fax:
Mailing address:
  • Phone: 301-934-9111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberR162903
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberR162903
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: JAMIE REIDY
Title or Position: OWNER AND NURSE PRACTITIONER
Credential: CRNP
Phone: 13-934-9111