Healthcare Provider Details

I. General information

NPI: 1306539861
Provider Name (Legal Business Name): ABDUL-HAKEEM MUSTAPHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 GLYNOCK PL
REISTERSTOWN MD
21136-1726
US

IV. Provider business mailing address

615 GLYNOCK PL
REISTERSTOWN MD
21136-1726
US

V. Phone/Fax

Practice location:
  • Phone: 507-513-0125
  • Fax:
Mailing address:
  • Phone: 507-513-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33296
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: