Healthcare Provider Details

I. General information

NPI: 1205079746
Provider Name (Legal Business Name): COQUUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 06/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 INDUSTRIAL PARK DR SUITE 202 F
WALDORF MD
20602-2751
US

IV. Provider business mailing address

21 INDUSTRIAL PARK DR SUITE 202 F
WALDORF MD
20602-2751
US

V. Phone/Fax

Practice location:
  • Phone: 301-848-0461
  • Fax: 301-885-0922
Mailing address:
  • Phone: 301-848-0461
  • Fax: 301-885-0922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number02983
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number05567
License Number StateMD

VIII. Authorized Official

Name: DR. PATRICIA VANCE
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 301-848-0461