Healthcare Provider Details

I. General information

NPI: 1255148466
Provider Name (Legal Business Name): CEDRIC YVANN IRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 REISTERSTOWN RD
PIKESVILLE MD
21208-4325
US

IV. Provider business mailing address

1517 REISTERSTOWN RD
PIKESVILLE MD
21208-4325
US

V. Phone/Fax

Practice location:
  • Phone: 410-541-1316
  • Fax:
Mailing address:
  • Phone: 410-541-1316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: