Healthcare Provider Details

I. General information

NPI: 1083311138
Provider Name (Legal Business Name): PNAG, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 PROVIDENCE RD
TOWSON MD
21286-1525
US

IV. Provider business mailing address

1620 PROVIDENCE RD
TOWSON MD
21286-1525
US

V. Phone/Fax

Practice location:
  • Phone: 410-231-7556
  • Fax:
Mailing address:
  • Phone: 410-231-7556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: PHYLLIS GUTHUA
Title or Position: PSYCHOLOGIST
Credential: PSY.D.
Phone: 410-803-3427