Healthcare Provider Details

I. General information

NPI: 1346867173
Provider Name (Legal Business Name): CHARLOTTE G BOSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2020
Last Update Date: 06/27/2020
Certification Date: 06/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SLADE AVE
PIKESVILLE MD
21208-4900
US

IV. Provider business mailing address

124 SLADE AVE
PIKESVILLE MD
21208-4900
US

V. Phone/Fax

Practice location:
  • Phone: 410-855-4448
  • Fax: 443-548-2800
Mailing address:
  • Phone: 410-855-4448
  • Fax: 443-548-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberATC112
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: