Healthcare Provider Details

I. General information

NPI: 1104886308
Provider Name (Legal Business Name): ELLEN HARRIET PAINTER LSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PICCARD DR 2ND FLOOR/ EMERGENCY SERVICES
ROCKVILLE MD
20850-4320
US

IV. Provider business mailing address

7520 SWEET HOURS WAY D
COLUMBIA MD
21046-2482
US

V. Phone/Fax

Practice location:
  • Phone: 240-777-4143
  • Fax: 240-777-4189
Mailing address:
  • Phone: 301-854-9025
  • Fax: 301-854-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberA02090
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: