Healthcare Provider Details

I. General information

NPI: 1477580728
Provider Name (Legal Business Name): LISA SALLADIN CHILDS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 FALLS RD
MONKTON MD
21111-1621
US

IV. Provider business mailing address

16260 FALLS RD
MONKTON MD
21111-1621
US

V. Phone/Fax

Practice location:
  • Phone: 410-409-8731
  • Fax: 443-238-0201
Mailing address:
  • Phone: 410-409-8731
  • Fax: 443-238-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number08666
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier402510501
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: