Healthcare Provider Details

I. General information

NPI: 1174628846
Provider Name (Legal Business Name): IRENE MICHELLE MEDNICK L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13809 GREY COLT DR
NORTH POTOMAC MD
20878-3865
US

IV. Provider business mailing address

13809 GREY COLT DR
NORTH POTOMAC MD
20878-3865
US

V. Phone/Fax

Practice location:
  • Phone: 512-506-9614
  • Fax:
Mailing address:
  • Phone: 512-506-9614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number16805
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number38010
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: