Healthcare Provider Details

I. General information

NPI: 1154767697
Provider Name (Legal Business Name): INTERDYNAMICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 FORBES BLVD SUITE #100
LANHAM MD
20706-4807
US

IV. Provider business mailing address

4601 FORBES BLVD SUITE #100
LANHAM MD
20706-4807
US

V. Phone/Fax

Practice location:
  • Phone: 301-306-4590
  • Fax: 301-306-4590
Mailing address:
  • Phone: 301-306-4590
  • Fax: 301-306-4590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14082
License Number StateMD

VIII. Authorized Official

Name: MARY MITCHELL
Title or Position: ADMINISTRATIVE PROJECT MANAGER
Credential:
Phone: 301-306-4590