Healthcare Provider Details

I. General information

NPI: 1295776698
Provider Name (Legal Business Name): MEHRYAR TABIB LCSW-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E MAIN ST
SALISBURY MD
21804-5020
US

IV. Provider business mailing address

505 E MAIN ST
SALISBURY MD
21804-5020
US

V. Phone/Fax

Practice location:
  • Phone: 410-341-3420
  • Fax: 410-341-3397
Mailing address:
  • Phone: 410-341-3420
  • Fax: 410-341-3397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number07578
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number992792
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number07578
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: